Patient survey summary star rating. More stars are better.  4stars.png

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