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Hospital Infection Summary

Measure	Date Range	Value	State Average	National Average
Clostridium Difficile Infection (W_HI15) ?	01/01/18 to 12/31/18	9.14	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	0.23	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	0.28	0.33	n/a !	+ details	+ more info
Falls with Injury (W_FWI) ?	01/01/18 to 12/31/18	0.65	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	0.0%	1.2%	1.6% !	+ details	+ more info
Episiotomy (W_OB03) ?	01/01/18 to 12/31/18	2.9%	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	1.01	0.55	n/a !	+ details	+ more info
Knee Replacement Infection (W_SSIo02a) ?	01/01/18 to 12/31/18	0.00	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	0.00	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	2.65	0.65	1.00 !	+ details	+ more info
Central Line Bloodstream Infection outside the ICU (W_CLABSI02) ?	01/01/18 to 12/31/18	0.25	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	0.66	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	1.29	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	6.67	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	n/a !	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	64%	72%	73%	+ details	+ more info
Patients Recommend (CMS_HCP02a) ?	07/01/17 to 06/30/18	63%	73%	72%	+ details	+ more info
Nurse Communication (CMS_HCP03a) ?	07/01/17 to 06/30/18	75%	79%	80%	+ details	+ more info
Doctor Communication (CMS_HCP04a) ?	07/01/17 to 06/30/18	75%	81%	81%	+ details	+ more info
Staff Responsiveness (CMS_HCP05a) ?	07/01/17 to 06/30/18	59%	68%	70%	+ details	+ more info
Staff Explained Medicine (CMS_HCP07a) ?	07/01/17 to 06/30/18	58%	66%	66%	+ details	+ more info
Room Cleanliness (CMS_HCP08a) ?	07/01/17 to 06/30/18	75%	75%	75%	+ details	+ more info
Quiet at Night (CMS_HCP09a) ?	07/01/17 to 06/30/18	52%	54%	62%	+ details	+ more info
Provided Discharge Instructions (CMS_HCP10a) ?	07/01/17 to 06/30/18	83%	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	0.0%	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	289	274 !	256 !	+ details	+ more info
Minutes After Being Admitted Before Going To Room (CMS_ED02Min) ?	07/01/17 to 06/30/18	141	101 !	86 !	+ details	+ more info
Minutes in ED Before Going Home (CMS_ED03Min) ?	07/01/17 to 06/30/18	192	147 !	137 !	+ details	+ more info
Minutes in ED Before Seeing Caregiver (CMS_ED04Min) ?	04/01/17 to 03/31/18	36	24 !	19 !	+ details	+ more info
Brain Scan Results in 45 Mins (CMS_ED07) ?	07/01/17 to 06/30/18	88%	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	92%	91% !	93% !	+ details	+ more info
Health Care Worker Flu Immunization (W_HI03) ?	10/01/18 to 03/31/19	97%	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	1.1	1.0	1.0	+ details	+ more info
Complications for Hip/Knee Replacement (CMS_SC02) ?	04/01/14 to 03/31/17	2.6	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	15.9	15.3 !	16.0	+ details	+ more info
Heart Attack Mortality (CMS_30D02) ?	07/01/14 to 06/30/17	13.2	13.7 !	13.2	+ details	+ more info
Heart Failure Readmit (CMS_30D03) ?	07/01/14 to 06/30/17	22.3	20.8 !	21.7	+ details	+ more info
Heart Failure Mortality (CMS_30D04) ?	07/01/14 to 06/30/17	14.5	12.6 !	11.7	+ details	+ more info
Pneumonia Readmit (CMS_30D05) ?	07/01/14 to 06/30/17	17.0	15.9 !	16.7	+ details	+ more info
Pneumonia Mortality (CMS_30D06) ?	07/01/14 to 06/30/17	16.8	16.6 !	15.7	+ details	+ more info
Hip/Knee Readmit (CMS_30D07) ?	07/01/14 to 06/30/17	4.4	3.8 !	4.2	+ details	+ more info
Hospital-wide Readmit (CMS_30D08) ?	07/01/16 to 06/30/17	16.1	14.4 !	15.3	+ details	+ more info