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Summary of Hospital Quality Measures

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Deborah Heart and Lung Center
http://www.deborah.org

Recommended Care/Process of Care Measures
Higher Score is Better
  Hospital
Overall Score
State Median State Top 10%
Heart Attack (detail) 95 100
Pneumonia (detail) 0 ^ 99 100
Surgical Care Improvement (detail) 98 99 100
Heart Failure (detail) 100 100 100

^ Hospital score for this measure is based on a small number of patients (less than 25). Interpret data with caution.



Outcome of Care Measures: Mortality Inpatient Quality Indicator (IQI)
Lower Rate is Better
Hospital Rate National Average Rate (2012) Statewide Average Rate (2014)
Heart Attack 5.5 5.6 5.4
Pneumonia 1.7 3.5 2.3
Heart Failure 0.9 * 3.1 2.6
Stroke 8.5 ^ 8.3 7.3

* Statistically significantly below statewide average (better than average)

^ Rate is based on denominator less than 30 and should be taken with caution



Outcome of Care Measures: Coronary Artery Bypass Graft (CABG) Surgery Mortality
Lower Rate is Better
Hospital Rate State Rate
Number of Cases 119 3,881
Mortality Rate* 1.26 1.57
95% Confidence Interval (0.14, 4.56)
* Operative Mortality includes: (1) all deaths occurring during the hospitalization in which the operation was performed, even after 30 days; and (2) those deaths occurring after discharge from the hospital, but within 30 days of the procedures.



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 0.2 0.3 206 0.3
Post-operative hip fracture 0 0 4 0
Post-operative hemorrhage or hematoma 6.9 5.1 870 4.8
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT) 1.5 * 5 1164 6.1
Post-operative sepsis 22.4^ 9.6 156 10.4
Post-operative wound dehiscence 0^ 1.9 42 1.4
Accidental puncture or laceration 2.3 1.9 807 1.4
Transfusion reaction 0 38 1 NA
Birth Trauma+ - 1.9 151 1.5
Obstetric trauma - vaginal delivery with instrument+ - 133.2 410 112.6
Obstetric trauma - vaginal delivery without instrument+ - 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.

- (Missing) Hospital did not perform the procedure during the year; or it performed less than 3 procedures (rate is not calculated when the denominator is less than 3).

* 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
Catheter-Associated Urinary Tract Infections (CAUTI), 2014 Lower 0 Higher
Central Line-Associated Bloodstream Infections (CLABSI), 2014 Similar 1.19 Lower
Coronary Artery Bypass Graft (CABG) Infections, 2014 Similar 1.482 Similar
Overall Surgical Site Infections, 2014 Similar 1.482 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).


Cardiac Surgery Information and Reports
Outpatient measures for all hospitals [pdf 20k]
Healthcare Associated Infections (HAI) for all hospitals