Washington Hospital Quality
A service of the Washington State Hospital Association

PeaceHealth Peace Island Medical Center

San Juan County | 98250 | View Hospital »

Hospital Infection Summary

Measure Date Range Value State Average National Average
Clostridium Difficile Infection (W_HI15) ? 01/01/18 to 12/31/18 0.00 4.63 6.15 ! + details + more info
MRSA Infection (W_HI16) ? 01/01/18 to 12/31/18 0.00 0.04 0.05 ! + details + more info
Severe Sepsis and Septic Shock Mortality (W_SM) ? 01/01/18 to 12/31/18 n/a 0.09 n/a ! + details + more info

Nursing Sensitive Measures

Measure Date Range Value State Average National Average
Pressure Ulcer Rate: Stage 3, 4 and Unstageable (W_PU) ? 01/01/18 to 12/31/18 0.00 0.33 n/a ! + details + more info
Falls with Injury (W_FWI) ? 01/01/18 to 12/31/18 0.00 0.72 n/a ! + details + more info

Safe Deliveries

Measure Date Range Value State Average National Average
Elective Delivery (W_OB01) ? 01/01/18 to 12/31/18 n/a ! 1.2% 1.6% ! + details + more info
Episiotomy (W_OB03) ? 01/01/18 to 12/31/18 n/a ! 2.1% 7.8% ! + details + more info

Infections: Cardiac Surgery

Measure Date Range Value State Average National Average
Cardiac Surgery Infection (W_SSIc01a) ? 01/01/18 to 12/31/18 n/a ! 0.32 n/a ! + details + more info

Infections: Ortho Surgery

Measure Date Range Value State Average National Average
Hip Replacement Infection (W_SSIo01a) ? 01/01/18 to 12/31/18 n/a ! 0.55 n/a ! + details + more info
Knee Replacement Infection (W_SSIo02a) ? 01/01/18 to 12/31/18 n/a ! 0.35 n/a ! + details + more info

Infections: Hysterectomy

Measure Date Range Value State Average National Average
Abdominal Hysterectomy Infection (W_SSIh01a) ? 01/01/18 to 12/31/18 n/a ! 0.30 n/a ! + details + more info

Infections: CLABSI

Measure Date Range Value State Average National Average
Central Line Bloodstream Infection in the ICU (W_CLABSI01) ? 01/01/18 to 12/31/18 n/a ! 0.65 1.00 ! + details + more info
Central Line Bloodstream Infection outside the ICU (W_CLABSI02) ? 01/01/18 to 12/31/18 0.00 0.42 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) ? 01/01/18 to 12/31/18 n/a ! 1.30 0.81 ! + details + more info
Catheter-Associated Urinary Tract Infections outside of the ICU (W_CAUTI02) ? 01/01/18 to 12/31/18 0.00 1.00 n/a ! + details + more info

Infections: Colon

Measure Date Range Value State Average National Average
Surgical Infection Colon (W_HI09) ? 01/01/18 to 12/31/18 n/a ! 1.54 n/a ! + details + more info

Heart Attack

Measure Date Range Value State Average National Average
Outpatient Blood Clot Drugs w/in 30 Mins (CMS_AMI20) ? 07/01/17 to 06/30/18 n/a ! 56% ! 59% ! + details + more info
Outpatient Minutes to Transfer (CMS_AMI22Min) ? 07/01/17 to 06/30/18 n/a ! 58 ! 62 ! + details + more info
Outpatient Minutes to ECG (CMS_AMI23Min) ? 07/01/17 to 06/30/18 10 9 ! 8 ! + details + more info

Patient Satisfaction

Measure Date Range Value State Average National Average
Overall Satisfaction Rating (CMS_HCP01a) ? 07/01/17 to 06/30/18 n/a ! 72% 73% + details + more info
Patients Recommend (CMS_HCP02a) ? 07/01/17 to 06/30/18 n/a ! 73% 72% + details + more info
Nurse Communication (CMS_HCP03a) ? 07/01/17 to 06/30/18 n/a ! 79% 80% + details + more info
Doctor Communication (CMS_HCP04a) ? 07/01/17 to 06/30/18 n/a ! 81% 81% + details + more info
Staff Responsiveness (CMS_HCP05a) ? 07/01/17 to 06/30/18 n/a ! 68% 70% + details + more info
Staff Explained Medicine (CMS_HCP07a) ? 07/01/17 to 06/30/18 n/a ! 66% 66% + details + more info
Room Cleanliness (CMS_HCP08a) ? 07/01/17 to 06/30/18 n/a ! 75% 75% + details + more info
Quiet at Night (CMS_HCP09a) ? 07/01/17 to 06/30/18 n/a ! 54% 62% + details + more info
Provided Discharge Instructions (CMS_HCP10a) ? 07/01/17 to 06/30/18 n/a ! 89% 87% + details + more info

Medical Imaging

Measure Date Range Value State Average National Average
Outpatient Combination Chest Scans (CMS_MI04) ? 07/01/16 to 06/30/17 3.4% 0.5% 1.5% + details + more info

Emergency Department Care

Measure Date Range Value State Average National Average
Minutes in ED Before Admitted (CMS_ED01Min) ? 07/01/17 to 06/30/18 256 274 ! 256 ! + details + more info
Minutes After Being Admitted Before Going To Room (CMS_ED02Min) ? 07/01/17 to 06/30/18 62 101 ! 86 ! + details + more info
Minutes in ED Before Going Home (CMS_ED03Min) ? 07/01/17 to 06/30/18 123 147 ! 137 ! + details + more info
Minutes in ED Before Seeing Caregiver (CMS_ED04Min) ? 04/01/17 to 03/31/18 11 24 ! 19 ! + details + more info
Brain Scan Results in 45 Mins (CMS_ED07) ? 07/01/17 to 06/30/18 n/a ! 65% 73% + details + more info

Preventive Care

Measure Date Range Value State Average National Average
Patients Given Flu Vaccine (CMS_IMM02) ? 10/01/17 to 03/31/18 86% 91% ! 93% ! + details + more info
Health Care Worker Flu Immunization (W_HI03) ? 10/01/18 to 03/31/19 92% 92% 87% ! + details + more info

Surgical Complications

Measure Date Range Value State Average National Average
Serious Complications (CMS_SC01) ? 10/01/15 to 06/30/17 n/a ! 1.0 1.0 + details + more info
Complications for Hip/Knee Replacement (CMS_SC02) ? 04/01/14 to 03/31/17 n/a ! 2.5 ! 2.6 + details + more info

Blood Clot Prevention

Measure Date Range Value State Average National Average
Blood clot dev. and no preventive treatment provided (CMS_VTE06) ? 07/01/17 to 06/30/18 n/a ! 4% ! 3% ! + details + more info

30-Day Outcomes

Measure Date Range Value State Average National Average
Heart Attack Readmit (CMS_30D01) ? 07/01/14 to 06/30/17 n/a ! 15.3 ! 16.0 + details + more info
Heart Attack Mortality (CMS_30D02) ? 07/01/14 to 06/30/17 n/a ! 13.7 ! 13.2 + details + more info
Heart Failure Readmit (CMS_30D03) ? 07/01/14 to 06/30/17 n/a ! 20.8 ! 21.7 + details + more info
Heart Failure Mortality (CMS_30D04) ? 07/01/14 to 06/30/17 n/a ! 12.6 ! 11.7 + details + more info
Pneumonia Readmit (CMS_30D05) ? 07/01/14 to 06/30/17 16.5 15.9 ! 16.7 + details + more info
Pneumonia Mortality (CMS_30D06) ? 07/01/14 to 06/30/17 n/a ! 16.6 ! 15.7 + details + more info
Hip/Knee Readmit (CMS_30D07) ? 07/01/14 to 06/30/17 n/a ! 3.8 ! 4.2 + details + more info
Hospital-wide Readmit (CMS_30D08) ? 07/01/16 to 06/30/17 15.2 14.4 ! 15.3 + details + more info