Quality & Safety Report
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 |
67% |
61% |
63% |
82% |
Time Period: 10/1/2022 to 9/30/2023
Measure: Perinatal Care
| Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
| Elective Delivery |
0% |
2% |
4% |
0% |
Time Period: 10/1/2022 to 9/30/2023
Measure: Immunization
| Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
| Healthcare Worker Influenza Immunization |
97% |
81% |
84% |
N/A |
Time Period: 10/1/2022 to 3/31/2023
Measure: Outpatient ED
| Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
| Arrival to Departure Time (min) |
208 |
211 |
191 |
100 |
| Head CT/MRI Scan Results within 45 Minutes for Stroke Patients |
71% |
69% |
71% |
100% |
Time Period: 10/1/2022 to 9/30/2023
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 |
93% |
58% |
50% |
100% |
Time Period: 1/1/2022 to 12/31/2022
Measure: Tobacco Treatment
| Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
| Tobacco Use Treatment Provided or Offered |
92% |
71% |
81% |
99% |
| Tobacco Use Treatment Provided or Offered at Discharge |
97% |
58% |
66% |
98% |
Time Period: 1/1/2022 to 12/31/2022
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 |
82% |
60% |
42% |
100% |
| Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge |
100% |
72% |
61% |
100% |
Time Period: 1/1/2022 to 12/31/2022
Measure: Screening for Metabolic Disorders
| Quality of Care Indicator |
Hospital Score |
National Average |
State Average |
Top 10% in the Nation |
| Screening for Metabolic Disorders |
98% |
79% |
84% |
100% |
Time Period: 1/1/2022 to 12/31/2022
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 |
98% |
92% |
92% |
100% |
Time Period: 1/1/2022 to 12/31/2022
Safety Report
30-Day Risk Adjusted Mortality Rates
|
Number of Patients |
Mortality Rate |
Hospital Measure Predicted Range from: |
Hospital Measure Predicted Range to: |
National Average |
| Heart Attack |
225 |
15.7% |
12.7% |
19.4% |
12.6% |
| Heart Failure |
346 |
13.7% |
10.8% |
17.1% |
11.9% |
| Pneumonia |
437 |
20.7% |
17.3% |
24.4% |
17.9% |
| COPD |
344 |
11.4% |
9.0% |
14.4% |
9.4% |
| Stroke |
206 |
18.4% |
14.7% |
23.0% |
13.9% |
| CABG |
128 |
4.9% |
2.7% |
8.4% |
2.8% |
Time Period: 7/1/2020 to 6/30/2023
30-Day Risk Adjusted Readmission Rates
|
Number of Patients |
Mortality Rate |
Hospital Measure Predicted Range from: |
Hospital Measure Predicted Range to: |
National Average |
| Heart Attack |
236 |
14.2% |
11.8% |
17.1% |
13.7% |
| Heart Failure |
409 |
22.2% |
19.3% |
25.1% |
19.8% |
| Pneumonia |
475 |
16.1% |
13.9% |
18.6% |
16.4% |
| COPD |
399 |
19.7% |
17.1% |
22.7% |
18.5% |
| CABG |
123 |
11.4% |
8.8% |
14.8% |
10.7% |
| Hip/Knee |
N/A |
N/A |
N/A |
N/A |
N/A |
| Hospital-Wide* |
3150 |
16.1% |
14.8% |
16.9% |
14.6% |
Time Period: 7/1/2020 to 6/30/2023 / *Time Period: 7/1/2022 to 6/30/2023
Satisfaction Report
| Satisfaction Indicator |
Hospital Score |
National Average |
State Average |
| Percent who said Nurses "Always" communicated well |
75% |
80% |
82% |
| Doctors "Always" communicated well |
77% |
80% |
84% |
| "Always" received help as soon as they wanted |
59% |
66% |
70% |
| Staff "Always" explained about medicines before giving it to them |
51% |
62% |
63% |
| Room and bathroom were "Always" clean |
58% |
73% |
73% |
| Area around their room was "Always" quiet at night |
55% |
62% |
68% |
| "Always" given information about what to do at home |
86% |
86% |
85% |
| Rated hospital a 9 or 10 on a scale from 0 (lowest) to 10 (highest) |
65% |
72% |
73% |
| "Always" would definitely recommend the hospital |
67% |
70% |
70% |
| Patients who "Strongly Agree" they understood their care when they left the hospital |
46% |
52% |
51% |
Time Period: 10/1/2022 to 9/30/2023
Data Source: CMS Hospital Compare www.medicare.gov/hospitalcompare
