Patient survey summary star rating. More stars are better. 
Patient Care Report
Measure: Sepsis
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Early Management Bundle, Severe Sepsis/Septic Shock |
88% |
60% |
65% |
82% |
Time Period: 1/1/2019 to 12/31/2019
Measure: Perinatal Care
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Elective Delivery |
1% |
2% |
2% |
0% |
Time Period: 1/1/2019 to 12/31/2019
Measure: Immunization
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Healthcare Worker Influenza Immunization |
N/A |
91% |
91% |
N/A |
Time Period: 10/1/2019 to 3/31/2020
Measure: Inpatient ED
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Admit Decision Time to ED Departure Time for Admitted Patients (Min) |
187 |
118 |
100 |
31 |
Time Period: 1/1/2019 to 12/31/2019
Measure: Outpatient ED
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Arrival to Departure Time (min) |
193 |
179 |
154 |
93 |
|
Head CT/MRI Scan Results within 45 Minutes for Stroke Patients |
64% |
72% |
72% |
100% |
Time Period: 1/1/2019 to 12/31/2019
Measure: Hospital Based Inpatient Psychiatric Services (HBIPS)
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Multiple Antipsychotic Meds w/Appropriate Justification |
64 |
72% |
72% |
100% |
Time Period: 1/1/2019 to 12/31/2019
Measure: Tobacco Treatment
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Tobacco Use Treatment Provided or Offered |
94% |
81% |
94% |
100% |
|
Tobacco Use Treatment Provided or Offered at Discharge |
94% |
57% |
81% |
99% |
Time Period: 1/1/2018 to 12/31/2018
Measure: Substance Use
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Alcohol Use Brief Intervention Provided or Offered |
91% |
83% |
83% |
100% |
|
Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge |
91% |
70% |
49% |
100% |
Time Period: 1/1/2018 to 12/31/2018
Measure: Screening for Metabolic Disorders
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Screening for Metabolic Disorders |
95% |
74% |
82% |
100% |
Time Period: 1/1/2018 to 12/31/2018
Measure: Outpatient AMI and Chest Pain
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Fibrinolytic within 30 Minutes |
NA |
58% |
53% |
100% |
Time Period: 1/1/2019 to 12/31/2019
Measure: Endoscopy
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Follow Up Interval for Normal Colonoscopy in Average Risk Patients |
94% |
89% |
86% |
100% |
|
Avoidance of Inappropriate Use |
90% |
93% |
86% |
100% |
Time Period: 1/1/2018 to 12/31/2018
Safety Report
30-Day Risk Adjusted Mortality Rates
|
Hospital Measure Predicted Range : |
|||||
|
Number Patients |
Mortality Rate |
from |
to |
National Average |
|
|
Heart Attack |
304 |
14.4% |
11.9% |
17.4% |
12.7% |
|
Heart Failure |
446 |
13.7% |
11.1% |
16.7% |
11.3% |
|
Pneumonia |
834 |
18.8% |
16.3% |
21.4% |
15.4% |
|
COPD |
530 |
10.6% |
8.5% |
12.8% |
8.4% |
|
Stroke |
300 |
16.9% |
14.0% |
20.3% |
13.6% |
|
CABG |
257 |
3.2% |
1.9% |
5.2% |
3.0% |
Time Period: 7/1/2016 to 6/30/2019
30-Day Risk Adjusted Readmission Rates
|
Hospital Measure Predicted Range : |
|||||
|
Number Patients |
Readmission Rate |
from |
to |
National Average |
|
|
Heart Attack |
316 |
17.5% |
14.9% |
20.6% |
16.1% |
|
Heart Failure |
543 |
23.9% |
21.1% |
27.0% |
21.9% |
|
Pneumonia |
958 |
19.2% |
17.2% |
21.4% |
16.6% |
|
COPD |
673 |
22.5% |
20.1% |
25.1% |
19.6% |
|
CABG |
249 |
13.7% |
10.7% |
17.5% |
12.7% |
|
Hip/Knee |
351 |
3.8% |
2.7% |
5.2% |
4.0% |
|
Hospital-wide |
3950 |
16.9% |
15.8% |
17.8% |
15.6% |
Time Period: 7/1/2016 to 6/30/2019
Satisfaction Report
|
Satisfaction Indicator |
Hospital Score |
National Average |
State Average |
|
Percent who said Nurses "Always" communicated well |
80% |
81% |
81% |
|
Doctors "Always" communicated well |
82% |
82% |
84% |
|
"Always" received help as soon as they wanted |
62% |
70% |
71% |
|
Staff "Always" explained about medicines before giving it to them |
61% |
66% |
66% |
|
Room and bathroom were "Always" clean |
72% |
76% |
76% |
|
Area around their room was "Always" quiet at night |
62% |
62% |
66% |
|
"Always" given information about what to do at home |
86% |
87% |
85% |
|
Rated hospital a 9 or 10 on a scale from 0 (lowest) to 10 (highest) |
72% |
73% |
72% |
|
"Always" would definitely recommend the hospital |
75% |
72% |
71% |
|
Patients who "Strongly Agree" they understood their care when they left the hospital |
50% |
54% |
54% |
Time Period: 1/1/2019 to 12/31/2019
Data Source: CMS Hospital Compare www.medicare.gov/hospitalcompare