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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

West Valley Community 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 85% of 274 patients 75% of 280 patients 71% of 275 patients 67% of 344 patients 64.1% of 365 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 4 5 5 7 92% 100.0% 94.0%
Element 1: Leadership Y N N Y 92% 100.0% 99.0%
Element 2: Accountability Y Y Y Y 92% 100.0% 99.0%
Element 3: Drug Expertise Y Y Y Y 92% 100.0% 98.0%
Element 4: Action Y Y Y Y 92% 100.0% 99.0%
Element 5: Tracking N N N Y 92% 100.0% 97.0%
Element 6: Reporting N Y Y Y 92% 100.0% 99.0%
Element 7: Education N Y Y Y 92% 100.0% 100.0%

Antibiotic Stewardship Trend in West Valley Community 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 14% of 278 patients 17% of 258 patients 100% 15.3% 16.5%

Opioid Rate Trend in West Valley Community Hospital