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 |
82% |
57% |
58% |
79% |
Time Period: 10/1/2020 to 9/30/2021
Measure: Perinatal Care
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Elective Delivery |
2% |
2% |
3% |
0% |
Time Period: 10/1/2020 to 9/30/2021
Measure: Immunization
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Healthcare Worker Influenza Immunization |
96% |
86% |
88% |
N/A |
Time Period: 10/1/2020 to 3/31/2021
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) |
182 |
198 |
170 |
100 |
|
Head CT/MRI Scan Results within 45 Minutes for Stroke Patients |
69% |
71% |
69% |
100% |
Time Period: 10/1/2020 to 9/30/2021
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 |
92% |
64% |
47% |
100% |
Time Period: 1/1/2020 to 12/31/2020
Measure: Tobacco Treatment
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Tobacco Use Treatment Provided or Offered |
98% |
80% |
90% |
100% |
|
Tobacco Use Treatment Provided or Offered at Discharge |
100% |
61% |
83% |
100% |
Time Period: 1/1/2020 to 12/31/2020
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 |
96% |
79% |
65% |
100% |
|
Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge |
98% |
75% |
60% |
100% |
Time Period: 1/1/2020 to 12/31/2020
Measure: Screening for Metabolic Disorders
|
Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
|
Screening for Metabolic Disorders |
100% |
77% |
81% |
100% |
Time Period: 1/1/2020 to 12/31/2020
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 |
53% |
40% |
100% |
Time Period: 10/1/2020 to 9/30/2021
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 |
93% |
90% |
89% |
100% |
|
Avoidance of Inappropriate Use |
90% |
93% |
86% |
100% |
Time Period: 1/1/2020 to 12/31/2020
Safety Report
30-Day Risk Adjusted Mortality Rates
|
Hospital Measure Predicted Range : |
|||||
|
Number Patients |
Mortality Rate |
from |
to |
National Average |
|
|
Heart Attack |
189 |
15.8% |
12.7% |
19.6% |
12.4% |
|
Heart Failure |
363 |
11.8% |
9.1% |
14.9% |
11.3% |
|
Pneumonia |
NA |
NA |
NA |
NA |
NA |
|
COPD |
304 |
10.0% |
7.7% |
13.1% |
8.4% |
|
Stroke |
202 |
17.1% |
13.8% |
21.0% |
13.6% |
|
CABG |
142 |
3.9% |
2.1% |
7.1% |
2.9% |
Time Period: 7/1/2018 to 6/30/2021
30-Day Risk Adjusted Readmission Rates
|
Hospital Measure Predicted Range : |
|||||
|
Number Patients |
Readmission Rate |
from |
to |
National Average |
|
|
Heart Attack |
190 |
15.5% |
12.8% |
18.9% |
15.0% |
|
Heart Failure |
426 |
24.4% |
21.6% |
27.6% |
21.3% |
|
Pneumonia |
NA |
NA |
NA |
NA |
NA |
|
COPD |
366 |
21.3% |
18.4% |
24.4% |
19.8% |
|
CABG |
136 |
13.0% |
9.6% |
17.2% |
11.9% |
|
Hip/Knee |
96 |
3.4% |
2.2% |
5.0% |
4.1% |
|
Hospital-wide |
3335 |
15.7% |
14.8% |
16.6% |
15.0% |
Time Period: 7/1/2018 to 6/30/2021 / *Time Period: 7/1/2020 to 6/30/2021
Satisfaction Report
|
Satisfaction Indicator |
Hospital Score |
National Average |
State Average |
|
Percent who said Nurses "Always" communicated well |
79% |
80% |
80% |
|
Doctors "Always" communicated well |
80% |
80% |
83% |
|
"Always" received help as soon as they wanted |
58% |
67% |
67% |
|
Staff "Always" explained about medicines before giving it to them |
57% |
63% |
62% |
|
Room and bathroom were "Always" clean |
63% |
73% |
72% |
|
Area around their room was "Always" quiet at night |
67% |
63% |
68% |
|
"Always" given information about what to do at home |
86% |
86% |
84% |
|
Rated hospital a 9 or 10 on a scale from 0 (lowest) to 10 (highest) |
70% |
72% |
71% |
|
"Always" would definitely recommend the hospital |
71% |
71% |
69% |
|
Patients who "Strongly Agree" they understood their care when they left the hospital |
53% |
52% |
51% |
Time Period: 10/1/2020 to 9/30/2021
Data Source: CMS Hospital Compare www.medicare.gov/hospitalcompare