Methodology and Definitions

Alegent Health Quality Measures

Alegent Health, along with a ationwide group of hospitals participates in the Hospital Quality Alliance, a quality assessment program managed by The Centers for Medicare and Medicaid Services (CMS). CMS is a Federal agency within the U.S. Department of Health and Human Services.

Participating hospitals agree to publicly report how often they provide recommended care known to get the best results for most patients being treated for heart attack, heart failure pneumonia, stroke, and pre- and post-operative care measures that are known to get the best results for most adult patients. Also reported are whether patients at risk have received certain vaccinations. Alegent Health's quality indicators reflect how often we provide the treatments known to get the best results.

Alegent Health has developed a Composite Scoring formula to report the quality of the overall care delivered for these important clinical conditions and their indicators. We calculate this percentage by the number of patients who actually received a particular treatment divided by the number of patients who should have received a particular treatment. To get a composite score for each clinical area, we add all the numerators for each measure and divide it by the sum of the denominators. To get a composite score for each clinical area, we add all the numerators for each measure and divide it by the sum of the denominators. We report scores for each hospital and as a system.

Heart Attack (AMI)

  1. Aspirin given at Arrival
  2. Aspirin given at Discharge
  3. Angiotensin Converting Enzyme Inhibitor (ACEI) for Left Ventricular Systolic Dysfunction (LVSD)
  4. Beta Blocker at Discharge
  5. Primary Percutaneous Coronary Intervention (PCI) within 90 Minutes of arrival (Angioplasty
  6. Fibrinolytic Therapy administered within 30 Minutes of arrival (Clot busting drugs Administered)

Heart Failure (HF)

  1. ACEI or ARB for LVSD ACEI
  2. Discharge Instructions

The Surgical Care Improvement Project (SCIP)

  1. Antibiotics One Hour Prior to procedure
  2. Selection from Recommended Antibiotics
  3. Antibiotics Discontinued within 24 hours
  4. Cardiac Patients with controlled 6 AM Post-op Blood Glucose
  5. Appropriate Pre-operative Hair Removal
  6. Beta Blocker Prior to Admission
  7. SCIP VTE Prophylaxis Given
  8. SCIP VTE Prophylaxis Ordered

Pneumonia (PN)

  1. Blood Culture within 24 hours of Arrival for ICU Patients
  2. Blood Culture in ED Before First Antibiotic
  3. Use of Recommended Antibiotics (ICU)
  4. Use of Recommended Antibiotics (Non-ICU)


  1. DVT Prophylaxis Given
  2. Discharged with Anti-thrombotic Therapy
  3. Patients with Atrial Fib Receiving Anti-Coagulation
  4. Thrombolytic Therapy Administrered by End of Day Two
  5. Discharged on Statin Medication
  6. Sroke Education
  7. Assessed for Rehabilitation


  1. Pneumoccocal Immunization
  2. Influenza Vaccination