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

79%

59%

64%

81%

Time Period: 7/1/2018 to 6/30/2019

Measure: Perinatal Care

Quality of Care Indicator

Hospital Score 

National Average

State Average

Top 10% in the Nation

Elective Delivery

4%

2%

2%

0%

Time Period: 7/1/2018 to 6/30/2019

Measure: Immunization

Quality of Care Indicator

Hospital Score 

National Average

State Average

Top 10% in the Nation

Healthcare Worker Influenza Immunization

95%

90%

90%

100%

Time Period: 10/1/2018 to 3/31/2019

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)

139

120

98

31

Time Period: 7/1/2018 to 6/30/2019

Measure: Outpatient ED

Quality of Care Indicator

Hospital Score 

National Average

State Average

Top 10% in the Nation

Arrival to Departure Time (min)

213

176

157

93

Head CT/MRI Scan Results within 45 Minutes for Stroke Patients

60%

72%

73%

100%

Time Period: 7/1/2018 to 6/30/2019

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

75%

61%

68%

100%

Time Period: 1/1/2018 to 12/31/2018

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%

58%

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%

57%

100%

Time Period: 7/1/2018 to 6/30/2019

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

Readmission Rate

from

to

National Average

Heart Attack

318

15.2%

12.6%

18.4%

12.9%

Heart Failure

438

16.4%

13.4%

19.7%

11.5%

Pneumonia

823

19.3%

16.7%

21.8%

15.6%

COPD

575

10.0%

  8.2%

12.2%

  8.5%

Stroke

284

16.9%

14.0%

20.4%

13.8%

CABG

273

  3.1%

  1.9%

  5.2%

  3.1%

Time Period: 7/1/2015 to 6/30/2018

30-Day Risk Adjusted Readmission Rates

     

Hospital Measure Predicted Range :

 

Number Patients

Readmission Rate

from

to

National Average

Heart Attack

325

17.2%

14.6%

20.2%

15.7%

Heart Failure

537

24.2%

21.3%

27.3%

21.6%

Pneumonia

934

18.3%

16.3%

20.6%

16.6%

COPD

762

23.3%

21.0%

25.9%

19.5%

CABG

269

14.1%

11.2%

17.7%

12.8%

Hip/Knee

443

  3.8%

  2.7%

  5.1%

  4.0%

Hospital-wide

3954

17.3%

15.7%

18.1%

15.3%

Time Period: 7/1/2015 to 6/30/2018

Satisfaction Report

Satisfaction Indicator

Hospital Score

National Average

State Average

Percent who said Nurses "Always" communicated well

79%

81%

81%

Doctors "Always" communicated well

81%

82%

84%

"Always" received help as soon as they wanted

61%

70%

72%

Staff "Always" explained about medicines before giving it to them

61%

66%

66%

Room and bathroom were "Always" clean

72%

76%

77%

Area around their room was "Always" quiet at night

63%

62%

67%

"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%

73%

"Always" would definitely recommend the hospital

75%

72%

71%

Patients who "Strongly Agree" they understood their care when they left the hospital

52%

53%

52%

Time Period: 7/1/2018 to 6/30/2019

Data Source: CMS Hospital Compare   www.medicare.gov/hospitalcompare