Info for Accreditation and State Reviews for Finley Hospital in Dubuque Iowa

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Preventing and Responding to Patient Harm

Mensurate proper name	Leapfrog's Standard	Hospital's Progress
Effective Leadership to Forbid Errors	Hospitals should have meaningful steps to enhance awareness most patient safe, hold leadership answerable for reducing dangerous practices, provide resources to implement a patient safety plan, and develop systems and structures to back up activity to improve patient safety. more than	SOME Achievement
	Prove more on this hospital's performance Evidence less This hospital scored 73.85 out of 120.00 possible points.
Staff Work Together to Prevent Errors	Hospitals should assess their civilisation of prophylactic and hold leadership answerable for implementing policies, procedures, and staff education to improve the civilization of safety. more	CONSIDERABLE ACHIEVEMENT
	Show more on this infirmary's performance Evidence less This hospital scored 100.00 out of 120.00 possible points.
Support for Nursing Workforce	Hospitals should assess their nursing staff levels and core competencies, included nurses in leadership, and develop and implement plans to accost any areas of improvement. more	CONSIDERABLE Accomplishment
	Show more on this hospital'south operation Evidence less This hospital scored 88.24 out of 100.00 possible points.
Handwashing	Hospitals should regularly monitor mitt hygiene practices for everyone interacting with patients, and requite feedback to ensure compliance. Hospitals should foster a civilization of skilful hand hygiene, offer training and educational activity, and provide equipment, such as paper towels, lather dispensers, and mitt sanitizer. more	LIMITED ACHIEVEMENT
	Show more on this hospital'south performance Show less Hand Hygiene Domain Performance Hospital regularly monitors hand hygiene practices Did not meet the requirements for monitoring. Feedback provided to ensure compliance with mitt hygiene Did Not Run across Appropriate grooming and education provided Did Not Encounter Access to newspaper towels, soap dispensers, and paw sanitizer maintained Did Not Come across Culture of good hand hygiene emphasized Met
Responding to Never Events	Hospitals should have a never events policy that includes all nine (ix) actions that should occur following a "never issue," which includes apologizing to the patient and not charging for costs associated with the never event. more	ACHIEVED THE STANDARD

Medication Safety

Mensurate proper name	Leapfrog's Standard	Hospital's Progress
Safe Medication Administration	Hospitals should accept nurses and other clinicians apply BCMA in all medical/surgical units, intensive care units, and labor and delivery units to scan the patient and medication prior to administration at to the lowest degree 95% of the fourth dimension. The BCMA organization includes decision support to foreclose errors and the hospital has processes to forbid workarounds. more	DECLINED TO Answer
Safe Medication Ordering	Hospitals should enter at least 85% of inpatient medication orders through the CPOE system. more	Accomplished THE STANDARD
	Show more than on this hospital'southward performance Show less This infirmary's percentage of inpatient medication orders entered electronically: 85% or greater
Medication Reconciliation	Hospitals should take a rate of unintentional medication discrepancies per medication that is lower than or equal to the 50th percentile (where lower operation is better) nationally. more	DECLINED TO RESPOND
Medication Documentation for Elective Outpatient Surgery Patients	Hospitals should document xc% or more of habitation medications, visit medications, and allergies/adverse reaction(due south) in the patients' clinical tape. more	DECLINED TO RESPOND

Healthcare Associated Infections

Measure proper noun	Leapfrog's Standard	Infirmary'southward Progress
Infection in the Blood	Hospitals should have fewer than expected fundamental-line associated blood stream infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safe Network (NHSN) to compare the number of infections that actually happened at this infirmary to the number of infections expected for this hospital, given various factors. A number lower than 1 means fewer infections than expected; a number more than i means more infections than expected. more	Limited Achievement
	Show more on this hospital's operation Show less This infirmary's standardized infection ratio (SIR) is: ane.832 Note: The standardized infection ratio (SIR) includes some information collected during the COVID-19 pandemic.
Infection in the Urinary Tract	Hospitals should have fewer than expected catheter-associated urinary tract infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given diverse factors. A number lower than one means fewer infections than expected; a number more than than i means more than infections than expected. more than	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital's performance Show less This hospital'due south standardized infection ratio (SIR) is: 0.428 Note: The standardized infection ratio (SIR) includes some data collected during the COVID-nineteen pandemic.
C. difficile Infection	Hospitals should have fewer than expected colon infections from C. diff bacteria. Leapfrog uses a standardized infection ratio (SIR) calculated past the CDC'due south National Healthcare Safety Network (NHSN) to compare the number of infections that really happened at this hospital to the number of infections expected for this hospital, given diverse factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more	Achieved THE STANDARD
	Show more than on this hospital's performance Testify less This infirmary's standardized infection ratio (SIR) is: 0.161 Annotation: The standardized infection ratio (SIR) includes some data nerveless during the COVID-nineteen pandemic.
MRSA Infection	Hospitals should have fewer than expected antibiotic resistant bacterial infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Rubber Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this infirmary, given various factors. A number lower than ane means fewer infections than expected; a number more than one ways more infections than expected. more than	UNABLE TO CALCULATE Sample size too small-scale to calculate score
Surgical Site Infection After Colon Surgery	Hospitals should have fewer than expected surgical site infections after major colon surgery. Leapfrog uses a standardized infection ratio (SIR) calculated past the CDC's National Healthcare Rubber Network (NHSN) to compare the number of infections that really happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than than one means more infections than expected. more	ACHIEVED THE STANDARD
	Show more on this hospital's performance Evidence less This hospital's standardized infection ratio (SIR) is: 0.000 Notation: The standardized infection ratio (SIR) includes some data collected during the COVID-19 pandemic.

Motherhood Care

Mensurate name	Leapfrog's Standard	Hospital's Progress
Cesarean Sections	This is divers as first-time mothers giving birth to a single baby, at full-term, in the caput-down position deliver their babies through a C-section. Hospitals should accept a rate of C-sections of 23.6% or less. more	SOME Achievement
	Show more on this hospital'southward operation Evidence less This hospital'southward rate of Cesarean sections is25.v%
Early Elective Deliveries	This is defined as mothers being scheduled for cesarean sections or medication inductions prior to 39 weeks gestation without a medical reason. Hospitals should take a rate of early on elective deliveries of v% or less. more	CONSIDERABLE Achievement
	Prove more on this hospital'due south operation Show less This hospital'due south rate of early elective deliveries is6.1%
Episiotomies	This is divers equally mothers having an incision made in the perineum (the nascency canal) during childbirth. Hospitals should take a charge per unit of episiotomies of 5% or less. more	CONSIDERABLE ACHIEVEMENT
	Evidence more on this hospital's functioning Evidence less This hospital's rate of episiotomies is5.9%
Screening Newborns for Jaundice Before Belch	Hospitals should screen at least xc% of babies for jaundice. more	Achieved THE STANDARD
	Evidence more on this infirmary's performance Show less This hospital'southward rate of screening newborns for jaundice before discharge is100.0%
Preventing Blood Clots in Women Undergoing Cesarean Section	At least ninety% of women undergoing a cesarean section receive treatment to prevent blood clots. more	ACHIEVED THE STANDARD
	Bear witness more than on this hospital's performance Show less This hospital'due south rate of preventing blood clots in women undergoing cesarean section93.three%
High-Run a risk Deliveries	Hospitals should deliver at least 50 very-low nascency weight babies per year OR the hospital must maintain a lower-than-average morbidity/bloodshed rate for very-depression birth weight babies. more	DOES Not Use

More Information

Number of Live Births

The hospital had606 live births (i.e., liveborn infants) at this hospital location for the reporting time period.

Pediatric Care

Measure proper name	Leapfrog's Standard	Hospital'southward Progress
Experience of Children and Their Parents	Hospitals should perform amend than near hospitals in five (v) areas: Communication with Parent – Communication most your child'south medicines Communication with Parent – Keeping yous informed nigh your child'due south care Communication with Child – How well nurses communicate with your child Communication with Child – How well doctors communicate with your child Attention to Safety and Condolement – Preventing mistakes and helping you report concerns. more	DECLINED TO Reply
Radiations Dose for Belly/Pelvis Scans	Hospitals should utilise a CT radiation dose for routine CT scans of the belly and pelvis that falls within national benchmarks. more than	DECLINED TO RESPOND
Radiation Dose for Caput Scans	Hospitals should have an average radiation dose for routine CT scans of the head that falls within national benchmarks. more	DECLINED TO Answer

Critical Care

Measure proper name	Leapfrog'south Standard	Hospital's Progress
Specially Trained Doctors Care for Critical Care Patients	Hospitals should have intensivists nowadays on-site at to the lowest degree 8 hours a mean solar day, vii days per week or has intensivists present via 24/vii telemedicine with some on-site intensivist presence. When not in the ICU, the intensivist immediately responds to calls and has another doc or trained clinician who tin can immediately achieve the patient. more	LIMITED ACHIEVEMENT

Complex Developed and Pediatric Surgery

Mensurate name	Leapfrog'due south Standard	Hospital'due south Progress
Carotid Avenue Surgery	Hospitals should perform at least 20 procedures annually, and every bit office of their procedure for privileging surgeons, ensure that each surgeon performs at least ten procedures annually. more than	DECLINED TO Reply
Mitral Valve Repair and Replacement	Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. In addition, hospitals should participate in a national clinical registry and accomplish the same or improve outcomes when compared to others who likewise perform this procedure. more	DECLINED TO Reply
Open Aortic Procedures	Hospitals should perform at to the lowest degree ten procedures annually, and equally function of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. more than	DECLINED TO RESPOND
Bariatric Surgery for Weight Loss	Hospitals should perform at to the lowest degree fifty procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at to the lowest degree twenty procedures annually. more	DECLINED TO RESPOND
Esophageal Resection for Cancer	Hospitals should perform at least twenty procedures annually, and every bit part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. more	DECLINED TO RESPOND
Lung Resection for Cancer	Hospitals should perform at to the lowest degree twoscore procedures annually, and as part of their procedure for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually. more	DECLINED TO RESPOND
Pancreatic Resection for Cancer	The infirmary performs at least xx procedures annually, and as function of their process for privileging surgeons, ensures that each surgeon performs at least ten procedures annually. more than	DECLINED TO RESPOND
Rectal Cancer Surgery	Hospitals should perform at least xvi procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least vi procedures annually. more than	DECLINED TO RESPOND
Full Hip Replacement Surgery	Hospitals should perform at least 50 procedures annually, and as function of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	DECLINED TO RESPOND
Total Knee Replacement Surgery	Hospitals should perform at least 50 procedures annually, and as function of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	DECLINED TO RESPOND
Built Eye Surgery for Infants (Norwood Procedure)	Hospitals should perform at least 8 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 5 procedures annually. more	DECLINED TO RESPOND

Care for Elective Outpatient Surgery Patients

Measure name	Leapfrog'southward Standard	Infirmary's Progress
Elective Outpatient Surgery Recovery Staffing - Adult	Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while an adult patient is present until discharge. more	DECLINED TO Answer
Elective Outpatient Surgery Recovery Staffing - Pediatric	Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while a pediatric patient is present until discharge. more	DECLINED TO RESPOND
Safe Surgery Checklist - Constituent Outpatient Surgery	Hospitals should go through all the elements of a complete rubber surgery checklist on all patients every time a process is performed. more than	DECLINED TO Reply
Experience of Patients Undergoing Elective Outpatient Surgery	Hospitals should perform better than most on 4 (4) areas including: (a) facilities and staff (b) communication about the procedure, (c) patients' overall rating of the facility, and (d) patients willingness to recommend the facility. more	DECLINED TO Reply

UnityPoint Wellness - Finley Hospital

350 N. Grandview Avenue
Dubuque, Iowa 52001-6388

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Source: https://ratings.leapfroggroup.org/facility/details/16-0117/unitypoint-health---finley-hospital-dubuque-ia

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