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Summary of Hospital Quality Measures

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Underwood-Memorial Hospital

Hospital is not licensed to perform CABG surgery.

General hospital licensing information is no longer available.
Recommended Care/Process of Care Measures
Higher Score is Better
  Hospital
Overall Score
State Median State Top 10%
Heart Attack (detail) 100 95 100
Pneumonia (detail) 100 99 100
Surgical Care Improvement (detail) 98 99 100
Heart Failure (detail) 100 100 100


Outcome of Care Measures: Mortality Inpatient Quality Indicator (IQI)
Lower Rate is Better
Hospital Rate National Average Rate (2016) Statewide Average Rate (2018)
Heart Attack 4.8 5.1 5
Pneumonia 2.3 2.8 2.5
Heart Failure 1.4 2.7 2.7
Stroke 9.8 7.4 6


Patient Safety Indicators
Lower Rate is Better
Hospital Rate National comparative ratea (2017) Statewide number of adverse events (2019) Satewide average rates (2019)
Retained Surgical Item or Unretrieved Device Fragment 0 619 13 NA
Iatrogenic pneumo thorax 0.4 0.2 97 0.1
In Hospital Fall with Hip Fracture 0 0.1 33 0.1
Post-operative hemorrhage or hematoma 7.4 ** 2.2 384 2.2
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT) 5.7 3.4 583 3.4
Post-operative sepsis 3.5 4.0 248 3.4
Post-operative wound dehiscence 1.9 0.7 14 0.3
Abdominopelvic Accidental Puncture or Laceration 1.6 1.0 113 0.9
Birth Trauma+ 10.8 4.8 173 1.9
Obstetric trauma - vaginal delivery with instrument+ 105.3^ 115.4 457 117.3
Obstetric trauma - vaginal delivery without instrument+ 26.7 17.6 859 14.6

+ 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.

** Worse than State Average (i.e. occurrence rate of adverse events is greater 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, 2018 --- 0 Similar
Catheter-Associated Urinary Tract Infections (CAUTI), 2018 Similar 0.95 Lower
Central Line-Associated Bloodstream Infections (CLABSI), 2018 Similar 1.42 Lower
Colon Surgical Site Infections, 2018 Similar 1.24 Lower
Knee Arthroplasty Surgical Site Infections, 2018 --- 0 Similar
Overall Surgical Site Infections, 2018 Similar 1.3 Lower

‡ Each hospital is compared to the National Ratio=1.

--- Standardized Infection Ratio (SIR) is not calculated because the Expected is < 1

Lower - indicates hospital infections are LOWER than infections seen nationally.

Similar -  indicates hospital infections are SIMILAR to infections seen nationally.


Outpatient measures for all hospitals [pdf 20k]
Healthcare Associated Infections (HAI) for all hospitals