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

Measure: Sepsis

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Early Management Bundle, Severe Sepsis/Septic Shock 74% 49% 47% 76%

Time Period: 10/1/2017 to 4/30/2018

Measure: Perinatal Care

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Elective Delivery 4% 2% 2% 0%
Cesarean Section 26% NA NA NA
Antenatal Steroids 100% NA NA NA
Health Care Associated Bloodstream Infections in Newborns 0% NA NA NA
Exclusive Breast Milk Feeding 50% NA NA NA

Time Period: 10/1/2017 to 4/30/2018

Measure: VTE

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Potentially Preventable VTE 0% 2% 2% 0%

Time Period: 10/1/2017 to 4/30/2018

Measure: Immunization

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Influenza Immunization 96.1% 93% 92% 100%

Time Period: 10/1/2017 to 4/30/2018

Measure: Inpatient ED

Quality of Care Indicator Hospital Score 1st Q 2018 National Average State Average Top 10% in the Nation
Median Time from ED Arrival to ED Departure for Admitted ED Patients (Min) 262 334 255 169
Admit Decision Time to ED Departure Time for Admitted Patients (Min) 167.5 140 120 35

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

Measure: Outpatient ED

Quality of Care Indicator Hospital Score 1st Q 2018 National Average State Average Top 10% in the Nation
Arrival to Departure Time (min) 184 171 156 94
Head CT/MRI Scan Results within 45 Minutes for Stroke Patients 33% 73% 70% 100%

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

Measure: Hospital Based Inpatient Psychiatric Services (HBIPS)

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Admission Screening 100% NA NA NA
Multiple Antipsychotic Meds w/Appropriate Justification 91.4% NA NA NA

Time Period: 10/1/2017 to 4/30/2018

Measure: Tobacco Treatment

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Tobacco Use Screening 99.8% NA NA NA
Tobacco Use Treatment Provided or Offered 93.1% NA NA NA
Tobacco Use Treatment Provided or Offered at Discharge 94.2% NA NA NA

Time Period: 10/1/2017 to 4/30/2018

Measure: Substance Use

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Alcohol Use Screening 98.7% NA NA NA
Alcohol Use Brief Intervention Provided or Offered 90% NA NA NA
Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge 89.6% NA NA NA

Time Period: 10/1/2017 to 4/30/2018

Measure: Hospital Based Inpatient Psychiatric Services (HBIPS) - Geri

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Admission Screening 100% NA NA NA
Multiple Antipsychotic Meds w/Appropriate Justification 62.5% NA NA NA

Time Period: 10/1/2017 to 4/30/2018

Measure: Substance Use - Geri

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Alcohol Use Screening 100% NA NA NA
Alcohol Use Brief Intervention Provided or Offered 100% NA NA NA
Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge 94.7% NA NA NA

Time Period: 10/1/2017 to 4/30/2018

Measure: Screening for Metabolic Disorders

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Screening for Metabolic Disorders 94% NA NA NA

Time Period: 10/1/2017 to 4/30/2018

Measure: Tobacco Treatment - Geri

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Tobacco Use Screening 100% NA NA NA
Tobacco Use Treatment Provided or Offered 93% NA NA NA
Tobacco Use Treatment Provided or Offered at Discharge 94% NA NA NA

Time Period: 10/1/2017 to 4/30/2018

Measure: Transition of Care

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Transition Record with Specified Elements Received by Discharged Patients 87% NA NA NA
Timely Transmission of Transition Record 86% NA NA NA

Time Period: 10/1/2017 to 4/30/2018

Measure: Outpatient AMI and Chest Pain

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Fibrinolytic within 30 Minutes NA 59% 49% 100%
Aspirin at Arrival 100% 95% 93% 100%

Time Period: 10/1/2017 to 4/30/2018

Measure: Outpatient Stroke

Quality of Care Indicator Hospital Score FY 2018 National Average State Average Top 10% in the Nation
Head CT/MRI Scan Results within 45 Minutes 44% 73% 70% 100%

Time Period: 10/1/2017 to 4/30/2018

Measure: Endoscopy

Quality of Care Indicator Hospital Score 1st Q 2018 National Average State Average Top 10% in the Nation
Follow Up Interval for Normal Colonoscopy in Average Risk Patients 94.1% 85% 73% 100%
Avoidance of Inappropriate Use 96.2% 90% 90% 100%

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

Safety Report

30-Day Risk Adjusted Mortality Rates

      Hospital Measure Predicted Range :
  Number Patients Readmission Rate from to National Average
Heart Attack 334 15.1% 11.8% 18% 13.6%
Heart Failure 448 15.9% 12.9% 18.4% 11.9%
Pneumonia 814 19.7% 16.6% 21.8% 15.9%

30-Day Risk Adjusted Readmission Rates

      Hospital Measure Predicted Range :
  Number Patients Readmission Rate from to National Average
Heart Attack 360 17.9% 15.1% 20.5% 16.3%
Heart Failure 556 27.1% 24.3% 29.9% 21.6%
Pneumonia 939 19% 17% 21.4% 16.9%

Data Source: CMS Hospital Compare July 2013 - June 2016

Satisfaction Report

Satisfaction Indicator Hospital Score 2nd Q 2018 National Average State Average Top 10% in the Nation
Percent who said Nurses "Always" communicated well 82% 80% 81% NA
Doctors "Always" communicated well 83% 82% 84% NA
"Always" received help as soon as they wanted 64% 70% 72% NA
Pain was "Always" well controlled 64% NA NA NA
Staff "Always" explained about medicines before giving it to them 66% 66% 67% NA
Room and bathroom were "Always" clean 73% 75% 75% NA
Area around their room was "Always" quiet at night 65% 62% 68% NA
"Always" given information about what to do at home 88% 87% 84% NA
Rated hospital a 9 or 10 on a scale from 0 (lowest) to 10 (highest) 74% 73% 73% NA
"Always" would definitely recommend the hospital 75% 72% 71% NA
Patients who "Strongly Agree" they understood their care when they left the hospital 51% 53% 52% NA