Washington Hospital Quality
A service of the Washington State Hospital Association

Cascade Valley Hospital & Clinics

Snohomish County | 98223 | View Hospital »

Hospital Infection Summary

Measure Date Range Value State Average National Average
Colon Surgery Infection (COLO) ? 4/1/15 to 3/31/16 3.6 4.7 3.3 + details + more info
Clostridium Difficile Infection (W_HI15) ? 7/1/15 to 6/30/16 7.2 ! 7.4 7.0 + details + more info
MRSA Infection (W_HI16) ? 7/1/15 to 6/30/16 0.0 ! 0.0 0.1 + details + more info
Health Care Worker Flu Immunization (W_HI03) ? 10/1/14 to 3/31/15 87.0% 87.0% 84.0% + details + more info

Safe Deliveries

Measure Date Range Value State Average National Average
Elective Delivery (W_OB01) ? 1/1/15 to 12/31/15 0.0% 1.1% n/a + details + more info
C-section in First Time Mothers (W_OB02) ? 1/1/14 to 12/31/14 28.2% 23.7% n/a + details + more info
Episiotomy (W_OB03) ? 4/1/15 to 3/31/16 1.9% 2.7% n/a + details + more info

Infections: Cardiac Surgery

Measure Date Range Value State Average National Average
Blood Sugar Under Control After Heart Surgery (CMS_SIP04) ? 4/1/13 to 3/31/14 ! 96% 94% + details + more info

Infections: Ortho Surgery

Measure Date Range Value State Average National Average
Hip Replacement Infection (W_SSIo01a) ? 4/1/15 to 3/31/16 0.0 0.9 n/a + details + more info
Knee Replacement Infection (W_SSIo02a) ? 4/1/15 to 3/31/16 0.0 0.6 n/a + details + more info

Infections: Hysterectomy

Measure Date Range Value State Average National Average
Abdominal Hysterectomy Infection (W_SSIh01a) ? 4/1/15 to 3/31/16 0.0 0.9 0.8 + details + more info

Infections: CLABSI

Measure Date Range Value State Average National Average
Central Line Bloodstream Infection in the ICU (W_CLABSI01) ? 7/1/15 to 6/30/16 0.0 ! 0.8 1.4 + details + more info
Central Line Bloodstream Infection outside the ICU (W_CLABSI02) ? 7/1/15 to 6/30/16 2.1 ! 0.9 n/a + details + more info

Infections: CAUTI

Measure Date Range Value State Average National Average
Catheter-Associated Urinary Tract Infections in the ICU (W_CAUTI01) ? 7/1/15 to 6/30/16 0.0 ! 1.2 1.6 + details + more info
Catheter-Associated Urinary Tract Infections outside of the ICU (W_CAUTI02) ? 7/1/15 to 6/30/16 0.0 ! 1.1 n/a + details + more info

Heart Attack

Measure Date Range Value State Average National Average
Aspirin at Discharge (CMS_AMI02) ? 10/1/13 to 9/30/14 ! 99% 99% + details + more info
Blood Clot Medicine at Arrival (CMS_AMI07) ? 10/1/14 to 9/30/15 ! 67% 55% + details + more info
Angioplasty at Arrival (CMS_AMI08) ? 10/1/14 to 9/30/15 ! 95% 95% + details + more info
Cholesterol Medicine at Discharge (CMS_AMI09) ? 4/1/13 to 12/31/13 ! 99% 98% + details + more info
Outpatient Blood Clot Drugs w/in 30 Mins (CMS_AMI20) ? 10/1/14 to 9/30/15 ! 56% 59% + details + more info
Outpatient Aspirin at Arrival (CMS_AMI21) ? 10/1/14 to 9/30/15 100% 97% 97% + details + more info
Outpatient Minutes to Transfer (CMS_AMI22Min) ? 10/1/14 to 9/30/15 ! 56 57 + details + more info
Outpatient Minutes to ECG (CMS_AMI23Min) ? 10/1/14 to 9/30/15 9 8 7 + details + more info

Heart Failure

Measure Date Range Value State Average National Average
Patients Received Discharge Instructions (CMS_HF01) ? 10/1/13 to 9/30/14 100% ! 91% 94% + details + more info
Left Ventricular Systolic Function Assessment (CMS_HF02) ? 10/1/14 to 9/30/15 100% ! 99% 98% + details + more info
ACE Inhibitor for Heart Function (CMS_HF03) ? 10/1/13 to 9/30/14 87% 96% 97% + details + more info

Pneumonia

Measure Date Range Value State Average National Average
Appropriate Initial Antibiotic (CMS_PNE06) ? 10/1/14 to 9/30/15 100% ! 95% 95% + details + more info

Surgical Care

Measure Date Range Value State Average National Average
Antibiotic Before Incision (CMS_SIP01) ? 10/1/14 to 9/30/15 100% ! 98% 99% + details + more info
Correct Antibiotic For Surgery (CMS_SIP02) ? 10/1/14 to 9/30/15 100% ! 99% 99% + details + more info
Antibiotic Stopped After Surgery (CMS_SIP03) ? 10/1/14 to 9/30/15 81% ! 98% 98% + details + more info
Catheters Removed on Time (CMS_SIP07) ? 10/1/14 to 9/30/15 100% ! 97% 98% + details + more info
Patient's Body Warm in Operating Room (CMS_SIP08) ? 10/1/13 to 9/30/14 100% ! 100% 100% + details + more info
Blood Clot Prevention (CMS_SIP22) ? 10/1/14 to 9/30/15 100% ! 100% 100% + details + more info
Patients on Beta Blockers (CMS_SIP23) ? 10/1/14 to 9/30/15 ! 97% 98% + details + more info
OP antibiotic timing (CMS_SIP31) ? 10/1/13 to 9/30/14 100% 98% 98% + details + more info
OP antibiotic selection (CMS_SIP32) ? 10/1/13 to 9/30/14 98% 98% 98% + details + more info

Patient Satisfaction

Measure Date Range Value State Average National Average
Overall Satisfaction Rating (CMS_HCP01a) ? 10/1/14 to 9/30/15 68% 71% 72% + details + more info
Patients Recommend (CMS_HCP02a) ? 10/1/14 to 9/30/15 68% 72% 71% + details + more info
Nurse Communication (CMS_HCP03a) ? 10/1/14 to 9/30/15 75% 78% 80% + details + more info
Doctor Communication (CMS_HCP04a) ? 10/1/14 to 9/30/15 73% 80% 82% + details + more info
Staff Responsiveness (CMS_HCP05a) ? 10/1/14 to 9/30/15 73% 65% 68% + details + more info
Pain Control (CMS_HCP06a) ? 10/1/14 to 9/30/15 66% 70% 71% + details + more info
Staff Explained Medicine (CMS_HCP07a) ? 10/1/14 to 9/30/15 62% 65% 65% + details + more info
Room Cleanliness (CMS_HCP08a) ? 10/1/14 to 9/30/15 77% 73% 74% + details + more info
Quiet at Night (CMS_HCP09a) ? 10/1/14 to 9/30/15 41% 55% 62% + details + more info
Provided Discharge Instructions (CMS_HCP10a) ? 10/1/14 to 9/30/15 85% 88% 87% + details + more info

Medical Imaging

Measure Date Range Value State Average National Average
Low back pain patients given MRI without trying treatment first. (CMS_MI01) ? 7/1/14 to 6/30/15 ! 41.1% 39.5% + details + more info
Outpatient Combination Chest Scans (CMS_MI04) ? 7/1/14 to 6/30/15 0.0% 0.8% 2.1% + details + more info

Emergency Department Care

Measure Date Range Value State Average National Average
Minutes in ED Before Admitted (CMS_ED01Min) ? 10/1/14 to 9/30/15 264 278 280 + details + more info
Minutes After Being Admitted Before Going To Room (CMS_ED02Min) ? 10/1/14 to 9/30/15 85 105 99 + details + more info
Minutes in ED Before Going Home (CMS_ED03Min) ? 10/1/14 to 9/30/15 106 145 142 + details + more info
Minutes in ED Before Seeing Caregiver (CMS_ED04Min) ? 10/1/14 to 9/30/15 25 24 23 + details + more info
Minutes in ED Before Pain Medication (CMS_ED05Min) ? 10/1/14 to 9/30/15 47 55 53 + details + more info
Left ED Without Being Seen (CMS_ED06) ? 1/1/14 to 12/31/14 0% 3% 2% + details + more info
Brain Scan Results in 45 Mins (CMS_ED07) ? 10/1/14 to 9/30/15 82% 64% 68% + details + more info

Preventive Care

Measure Date Range Value State Average National Average
Patients Given Flu Vaccine (CMS_IMM02) ? 10/1/14 to 3/31/15 96% 93% 94% + details + more info

Surgical Complications

Measure Date Range Value State Average National Average
Serious Complications (CMS_SC01) ? 7/1/13 to 6/30/15 2.3 n/a 2.3 + details + more info
Complications for Hip/Knee Replacement (CMS_SC02) ? 4/1/12 to 3/31/15 2.6% n/a 3.0% + details + more info

Stroke Care

Measure Date Range Value State Average National Average
Medicine To Break Up a Blood Clot Within Three Hours (CMS_STK01) ? 10/1/14 to 9/30/15 ! 97% 97% + details + more info
Medicine To Prevent Blood Clot Complication w/in Two Days (CMS_STK02) ? 10/1/14 to 9/30/15 ! 100% 99% + details + more info
Treatment to Keep Clots from Forming w/in Two Days (CMS_STK03) ? 10/1/14 to 9/30/15 ! 96% 97% + details + more info
Prescription to Prevent Complications Before Discharge (CMS_STK04) ? 10/1/14 to 9/30/15 ! 88% 84% + details + more info
Patients with irregular heartbeat given blood thinners (CMS_STK05) ? 10/1/14 to 9/30/15 ! 99% 98% + details + more info
Patients Who Needed it Given Prescription for Cholesterol Medication Before Discharge (CMS_STK06) ? 10/1/14 to 9/30/15 ! 97% 97% + details + more info
Written Educational Materials About Stroke Care Provided (CMS_STK08) ? 10/1/14 to 9/30/15 ! 93% 94% + details + more info
Stroke Patients Evaluated for Rehab Services (CMS_STK10) ? 10/1/14 to 9/30/15 ! 99% 98% + details + more info

Blood Clot Prevention

Measure Date Range Value State Average National Average
Treatment day of or day after admission (CMS_VTE01) ? 10/1/14 to 9/30/15 87% 92% 94% + details + more info
Treatment day of or day after ICU admit (CMS_VTE02) ? 10/1/14 to 9/30/15 87% 96% 97% + details + more info
Blood Clot Development and No Preventive Treatment Provided (CMS_VTE03) ? 10/1/14 to 9/30/15 87% 97% 94% + details + more info
Patients with Blood Clots Who Got Recommended Treatment (CMS_VTE04) ? 10/1/14 to 9/30/15 ! 99% 99% + details + more info
Patients with Blood Clot Checked for Risk of Increased Bleeding (CMS_VTE05) ? 10/1/14 to 9/30/15 100% 91% 92% + details + more info
Patients Discharged with Written Instructions (CMS_VTE06) ? 10/1/14 to 9/30/15 ! 3% 3% + details + more info

30-Day Outcomes

Measure Date Range Value State Average National Average
Heart Attack Readmit (CMS_30D01) ? 7/1/12 to 6/30/15 ! n/a 16.8% + details + more info
Heart Attack Mortality (CMS_30D02) ? 7/1/12 to 6/30/15 ! n/a 14.1% + details + more info
Heart Failure Readmit (CMS_30D03) ? 7/1/12 to 6/30/15 22.4% n/a 21.9% + details + more info
Heart Failure Mortality (CMS_30D04) ? 7/1/12 to 6/30/15 14.1% n/a 12.1% + details + more info
Pneumonia Readmit (CMS_30D05) ? 7/1/12 to 6/30/15 15.8% n/a 17.1% + details + more info
Pneumonia Mortality (CMS_30D06) ? 7/1/12 to 6/30/15 18.1% n/a 16.3% + details + more info
Hip/Knee Readmit (CMS_30D07) ? 7/1/12 to 6/30/15 4.4% n/a 4.6% + details + more info
Hospital-wide Readmit (CMS_30D08) ? 7/1/14 to 6/30/15 15.3% n/a 15.6% + details + more info