MBQIP.com
Measure Last Updated
HCP/IMM-3 Q4 2023 – Q1 2024

Influenza Vaccination Coverage Among Healthcare Personnel (HCP)

Antibiotic Stewardship 2024

Measured via Center for Disease Control National Healthcare Safety Network (CDC NHSN) Annual Facility Survey

Blue Mountain Hospital Q4 2020 – Q1 2021 Q4 2021 – Q1 2022 Q4 2022 – Q1 2023 Q4 2023 – Q1 2024 Q4 2024 – Q1 2025 OR CAH Rate Q4 2024 – Q1 2025 National CAH Rate Q4 2024 – Q1 2025
IMM-3 Influenza Vaccination Coverage Among Healthcare Personnel 84% of 354 patients 34% of 331 patients 30% of 247 patients 42% of 191 patients 21.1% of 222 patients 84.5% 75.0%

Influenza Vaccination Coverage Among Healthcare Personnel

Antibiotic Stewardship 2020 2022 2023 2024 % of OR CAHs Meeting Element (2024) State CAH Average (2024) National CAH Average (2024)
Number of Elements Met 6 7 7 0 92% 100.0% 94.0%
Element 1: Leadership Y Y Y N 92% 100.0% 99.0%
Element 2: Accountability Y Y Y N 92% 100.0% 99.0%
Element 3: Drug Expertise Y Y Y N 92% 100.0% 98.0%
Element 4: Action Y Y Y N 92% 100.0% 99.0%
Element 5: Tracking Y Y Y N 92% 100.0% 97.0%
Element 6: Reporting Y Y Y N 92% 100.0% 99.0%
Element 7: Education N Y Y N 92% 100.0% 100.0%

Antibiotic Stewardship Trend in Blue Mountain Hospital

Safe Use of Opioids 2023 2024 % of OR CAHs Meeting Element (2024) State CAH Rate (2024) National CAH Rate (2024)
Safe Use of Opioids Rate 6% of 30 patients 3% of 30 patients 100% 15.3% 16.5%

Opioid Rate Trend in Blue Mountain Hospital