| PERFORMANCE
AREAS |
Full
Survey
Performance Area
Scores
(09/12/2003)
|
National
Comparative
Data
Percent of Hospital Facilities
That Received a Score
of:
(n=1545) |
Updated
Performance
Area
Scores & Dates |
| 1 |
2 |
3 |
4 |
5 |
|
| Patient
Rights and Organizational Ethics |
|
| Patient
Rights |
1 |
73% |
23% |
4% |
0% |
0% |
|
|
| Organization
Ethics |
1 |
99% |
1% |
0% |
0% |
0% |
|
|
| Assessment
of Patients |
|
| Initial
Assessment Procedures |
1 |
32% |
29% |
20% |
10% |
9% |
|
|
| Pathology
and Clinical Laboratory Services |
1 |
92% |
6% |
2% |
0% |
0% |
|
|
| Reassessment
Procedures |
1 |
96% |
3% |
1% |
0% |
0% |
|
|
| Process
for Patient Care Decisions |
1 |
90% |
8% |
2% |
0% |
0% |
|
|
| Relevant
Policies |
1 |
97% |
3% |
0% |
0% |
0% |
|
|
| Needs
Assessment for Specific Patient Populations |
1 |
86% |
12% |
2% |
0% |
0% |
|
|
| Care of
Patients |
|
| Planning
and Providing Care |
1 |
78% |
15% |
5% |
1% |
1% |
|
|
| Anesthesia
Care |
1 |
87% |
9% |
2% |
1% |
1% |
|
|
| Medication
Use |
1 |
41% |
27% |
8% |
1% |
23% |
|
|
| Nutrition
Care |
1 |
94% |
6% |
0% |
0% |
0% |
|
|
| Operative
Procedures |
1 |
85% |
12% |
3% |
0% |
0% |
|
|
| Rehabilitation
Care |
1 |
93% |
6% |
1% |
0% |
0% |
|
|
| Special
Procedures |
1 |
61% |
23% |
12% |
2% |
2% |
|
|
| Education |
|
| Patient
and Family Education |
1 |
76% |
22% |
2% |
0% |
0% |
|
|
| Continuum
of Care |
|
| Continuum
of Care |
1 |
93% |
7% |
0% |
0% |
0% |
|
|
| Improving
Organization Performance |
|
| Design
of New Services |
1 |
98% |
2% |
0% |
0% |
0% |
|
|
| Measurement
of Processes and Outcomes |
1 |
88% |
9% |
3% |
0% |
0% |
|
|
| Assessment
of Data |
1 |
81% |
13% |
5% |
1% |
0% |
|
|
| Improvement
of Performance |
1 |
99% |
1% |
0% |
0% |
0% |
|
|
| Leadership |
|
| Strategic
Planning |
1 |
72% |
20% |
8% |
0% |
0% |
|
|
| Department
Leadership |
1 |
71% |
27% |
2% |
0% |
0% |
|
|
| Integrating
and Coordinating Services |
1 |
95% |
4% |
1% |
0% |
0% |
|
|
| Leaders'
Role in Improving Performance |
1 |
87% |
5% |
8% |
0% |
0% |
|
|
| Management
of the Environment of Care |
|
| Design
of the Environment |
2 |
41% |
54% |
5% |
0% |
0% |
|
|
| Implementation
of Safety Plans |
1 |
33% |
56% |
9% |
1% |
1% |
|
|
| Social
Environment |
1 |
77% |
22% |
1% |
0% |
0% |
|
|
| Monitoring
Safety Plans |
1 |
94% |
5% |
1% |
0% |
0% |
|
|
| Management
of Human Resources |
|
| Human
Resources Planning |
1 |
90% |
7% |
2% |
0% |
1% |
|
|
| Orientation,
Training, and Education of Staff |
1 |
70% |
19% |
10% |
1% |
0% |
|
|
| Assessing
Staff Competence |
1 |
48% |
26% |
9% |
8% |
9% |
|
|
| Managing
Staff Requests |
1 |
99% |
1% |
0% |
0% |
0% |
|
|
| Management
of Information |
|
| Information
Management Planning |
1 |
81% |
18% |
1% |
0% |
0% |
|
|
| Availability
of Patient-Specific Information |
2 |
30% |
42% |
18% |
6% |
4% |
|
|
| Data
Collection and Analysis |
1 |
98% |
2% |
0% |
0% |
0% |
|
|
| Literature
to Support Decision Making |
1 |
99% |
1% |
0% |
0% |
0% |
|
|
| Use
of Comparative Information |
1 |
100% |
0% |
0% |
0% |
0% |
|
|
| Surveillance,
Prevention and Control of Infection |
|
| Infection
Control |
1 |
46% |
48% |
5% |
0% |
1% |
|
|
| Governance |
|
| Governance |
1 |
97% |
2% |
1% |
0% |
0% |
|
|
| Management |
|
| Management |
1 |
100% |
0% |
0% |
0% |
0% |
|
|
| Medical
Staff |
|
| Organization,
Bylaws, Rules, and Regulations |
1 |
77% |
12% |
9% |
1% |
1% |
|
|
| Credentialing |
1 |
50% |
21% |
17% |
4% |
8% |
|
|
| Nursing |
|
| Nursing |
1 |
99% |
1% |
0% |
0% |
0% |
|
|
| Special
Type 1 Recommendations |
|
| Accreditation
Participation Requirements |
1 |
98% |
0% |
0% |
0% |
2% |
|
|
