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Summary of Hospital Quality Measures

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St. Clare's Hospital-Denville*
http://www.saintclares.org

Hospital is not licensed to perform CABG surgery.

Recommended Care/Process of Care Measures
Higher Score is Better
  Hospital
Overall Score
State Median State Top 10%
Heart Attack (detail) 93 95 100
Pneumonia (detail) 99 99 100
Surgical Care Improvement (detail) 99 99 100
Heart Failure (detail) 100 100 100
*Data for St. Clare's Hospital-Denville and St. Clare's Hospital-Dover are combined.


Outcome of Care Measures: Mortality Inpatient Quality Indicator (IQI)
Lower Rate is Better
Hospital Rate National Average Rate (2013) Statewide Average Rate (2015)
Heart Attack 5.5 5.4 5.8
Pneumonia 4.7 3 3
Heart Failure 0.9 3.4 2.5
Stroke 6.5 7.9 7


Patient Safety Indicators
Lower Rate is Better
Hospital Rate National average rate (2012) Statewide number of adverse events (2014) Statewide average rate (2014)
Retained Surgical Item or Unretrieved Device Fragment 0 973 32 NA
Iatrogenic pneumo thorax 0.1 0.3 206 0.3
Post-operative hip fracture 0 0 4 0
Post-operative hemorrhage or hematoma 4 5.1 870 4.8
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT) 2.7 * 5 1164 6.1
Post-operative sepsis 6.5 9.6 156 10.4
Post-operative wound dehiscence 0 1.9 42 1.4
Accidental puncture or laceration 1.9 1.9 807 1.4
Transfusion reaction 0 38 1 NA
Birth Trauma+ 2 1.9 151 1.5
Obstetric trauma - vaginal delivery with instrument+ 200^ 133.2 410 112.6
Obstetric trauma - vaginal delivery without instrument+ 33 21 962 16.4

+ Observed rate (not risk-adjusted)

Not applicable - Rate is not applicable for "Retained Surgical Item or Unretrieved Device Fragment Count" and "Transfusion Reaction". Both indicators are measured using volume instead of rate.

* Better than State Average (i.e. occurrence rate of adverse events is less than statewide rate).

^ Rate is based on less than 30 cases/patients and should be taken with caution.




Healthcare Associated Infections (HAIs)
  Hospital to
National Comparison‡
Standardized Infection Ratio (SIR) NJ Statewide to
National Comparison
Abdominal Hysterectomy Surgical Site Infections, 2014 --- --- Similar
Catheter-Associated Urinary Tract Infections (CAUTI), 2014 Similar 0 Higher
Central Line-Associated Bloodstream Infections (CLABSI), 2014 Similar 0 Lower
Colon Surgical Site Infections, 2014 Similar 0.297 Lower
Knee Arthroplasty Surgical Site Infections, 2014 --- --- Lower
Overall Surgical Site Infections, 2014 Similar 1.309 Lower

‡ Each hospital is compared to the National Ratio=1. The National Ratio is derived using the CDCs NHSN data from 2009 for CAUTI due to a definition change (AJIC, 2010).


Health System: Saint Clare's Health Services
Outpatient measures for all hospitals [pdf 20k]
Healthcare Associated Infections (HAI) for all hospitals