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Quality Background

  • Avera Quality Report Q&A

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Avera Quality Report Questions & Answers

Why is Avera publishing its Quality data?

We like what open reporting does for you. As a not-for-profit health care system and a community resource, we believe that you should know how we are performing.

We like what open reporting does for us. We have found that open reporting has helped us document our care more carefully, obtain more valid data, and give better patient care than we would have without public reporting.

We like what open reporting does for hospital care in general. We hope that our Quality Report will contribute to a better understanding of how to assess, report, and improve hospital quality.


Which clinical conditions are in this report?

Acute Myocardial Infarction (AMI), Heart Failure (HF), Community Acquired Pneumonia (CAP), and Hip and Knee Replacement. 


Does this Quality Report display data about individual physicians? 

No. We are publishing hospital data only.


What does this report tell me?

This report shows how Avera hospitals measure in quality compared to others in the study and those not participating in the study.


What is a numerator?

A numerator represents all patients in your hospital who actually received the prescribed treatment indicated by a particular measure.


What is a denominator?

A denominator represents all eligible patients in your hospital who should have received the prescribed treatment indicated by a particular measure.


Are the numerators and denominators of each indicator totaled by Medicare provider number?

Yes. If hospitals submit separately to Perspective™ and are combined into one Medicare provider number, then they are combined into these numerators and denominators.


What is the minimum number of cases by clinical condition to be included in the reporting?

A minimum of 30 cases per year in each for each clinical condition is the requirement for inclusion in the reporting. 


At what step are the minimal case thresholds applied?

Once the patients are assigned an APR Severity Level, cases where their APR-DRG category has an aggregate of less than 30 cases are excluded.