• Patient survey summary star rating. More stars are better.

Measure: Sepsis

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Early Management Bundle, Severe Sepsis/Septic Shock 78% NA NA NA

Time Period: 4/1/2015 to 3/31/2016

Measure: Stroke

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Thrombolytic Therapy within 3 hrs of Time Last Known Well NA 87 77 100

Time Period: 4/1/2015 to 3/31/2016

Measure: Perinatal Care

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Elective Delivery 0 2.0 3.0 0
Cesarean Section 29.6 NA NA NA
Antenatal Steroids 100 NA NA NA
Health Care Associated Bloodstream Infections in Newborns 0 NA NA NA
Exclusive Breast Milk Feeding 60.9 NA NA NA

Time Period: 4/1/2015 to 3/31/2016

Measure: VTE

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Potentially Preventable VTE 0 1.0% 1.0% 0

Time Period: 4/1/2015 to 3/31/2016

Measure: Immunization

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Influenza Immunization  95% 94% 93%  100%

Time Period: 4/1/2015 to 3/31/2016

Measure: Inpatient ED

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Median Time from ED Arrival to ED Departure for Admitted ED Patients (Min) 284 NA NA NA
Admit Decision Time to ED Departure Time for Admitted Patients (Min) 228 NA NA NA

Time Period: 4/1/2015 to 3/31/2016

Measure: Outpatient ED

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Median Time to Pain Management for Long Bone Fracture (Min) 60 52 60 31
Arrival to Departure Time (min) 180 NA NA NA
Door to Diagnostic Evaluation (min) 29 NA NA NA
Head CT/MRI Scan Results within 45 Minutes for Stroke Patients NA 69% 68% 100%

Time Period: 4/1/2015 to 3/31/2016

Measure: Hospital Based Inpatient Psychiatric Services (HBIPS)

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Admission Screening 100 NA NA NA
Physical Restraint Rate 0 NA NA NA
Seclusion Rate 0 NA NA NA
Multiple Antipsychotic Meds w/Appropriate Justification 100 NA NA NA

Time Period: 4/1/2015 to 3/31/2016

Measure: Tobacco Treatment

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Tobacco Use Screening 100 NA NA NA
Tobacco Use Treatment Provided or Offered 95.8 NA NA NA
Tobacco Use Treatment 4.2 NA NA NA
Tobacco Use Treatment Provided or Offered at Discharge 77.3 NA NA NA
Tobacco Use Treatment at Discharge 4.5 NA NA NA

Time Period: 4/1/2015 to 3/31/2016

Measure: Substance Use

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Alcohol Use Screening 98.3 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 100 NA NA NA

Time Period: 4/1/2015 to 3/31/2016

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

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Admission Screening 100 NA NA NA
Physical Restraint Rate 0 NA NA NA
Seclusion Rate 0 NA NA NA
Multiple Antipsychotic Meds w/Appropriate Justification 100 NA NA NA

Time Period: 4/1/2015 to 3/31/2016

Measure: Substance Use - Geri

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Alcohol Use Screening 100 NA NA NA
Alcohol Use Brief Intervention Provided or Offered NA NA NA NA
Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge 100 NA NA NA

Time Period: 4/1/2015 to 3/31/2016

Measure: Endoscopy

Quality of Care Indicator Hospital Score 4th Q 2016 National Average State Average Top 10% in the Nation
Follow Up Interval for Normal Colonoscopy in Average Risk Patients 100 80 77 100
Avoidance of Inappropriate Use 100 87 83 100

Time Period: 4/1/2015 to 3/31/2016

Safety Report

30-Day Risk Adjusted Mortality Rates

Hospital Measure Predicted Range :
Number Patients Mortality Rate from to
Heart Attack 365 14 11.4% 17.1%
Heart Failure 462 16.3% 13.7% 19.2%
Pneumonia 837 19.3% 17.1% 21.8%

30-Day Risk Adjusted Readmission Rates

Hospital Measure Predicted Range :
Number Patients Readmission Rate from to National Average
Heart Attack 409 18.8 15.9% 21.9% 16.8%
Heart Failure 581 25.2 22.5% 28.2% 21.9%
Pneumonia 979 19.5 17.4% 21.9% 17.1%

Data Source: CMS Hospital Compare April 2015 - March 2016

Satisfaction Report

Satisfaction Indicator Hospital Score 1st Q 2017 National Average State Average Top 10% in the Nation
Percent who said Nurses "Always" communicated well 81% 80% 81% NA
Doctors "Always" communicated well 83% 82% 84% NA
"Always" received help as soon as they wanted 60% 69% 71% NA
Pain was "Always" well controlled 71% 71% 73% NA
Staff "Always" explained about medicines before giving it to them 66% 65% 67% NA
Room and bathroom were "Always" clean 69% 74% 75% NA
Area around their room was "Always" quiet at night 66% 63% 69% NA
"Always" given information about what to do at home 86% 87% 84% NA
Rated hospital a 9 or 10 on a scale from 0 (lowest) to 10 (highest) 75% 72% 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 54% 52% 52% NA