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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 (2017)
Heart Attack 15.1 5.1 11
Pneumonia 3.7 2.8 3.6
Heart Failure 4.6 2.7 3.7
Stroke 8.8 7.4 5.9


Patient Safety Indicators
Lower Rate is Better
Hospital Rate National averages (2016) Statewide number of adverse events (2017) Statewide average rates (2017)
Retained Surgical Item or Unretrieved Device Fragment 0 694 16 NA
Iatrogenic pneumo thorax 0.4 0.2 113 0.2
In Hospital Fall with Hip Fracture 0.2 0.1 35 0.1
Post-operative hemorrhage or hematoma 5.2 ** 2.3 348 2.1
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT) 6.2 3.4 698 4.1
Post-operative sepsis 8.6 4 296 3.7
Post-operative wound dehiscence 0 0.7 27 0.6
Unrecognized Abdominopelvic Accidental Puncture or Laceration 1.9 0.7 99 0.9
Birth Trauma+ 11.1 4.6 206 2.2
Obstetric trauma - vaginal delivery with instrument+ 62.5 109.9 429 109.4
Obstetric trauma - vaginal delivery without instrument+ 17.1 17.3 843 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).




Healthcare Associated Infections (HAIs)
  Hospital to
National Comparison‡
Standardized Infection Ratio (SIR) NJ Statewide to
National Comparison
Abdominal Hysterectomy Surgical Site Infections, 2017 --- --- Similar
Catheter-Associated Urinary Tract Infections (CAUTI), 2017 Similar 1.351 Lower
Central Line-Associated Bloodstream Infections (CLABSI), 2017 Lower 0 Lower
Colon Surgical Site Infections, 2017 Similar 0.684 Lower
Knee Arthroplasty Surgical Site Infections, 2017 --- --- Similar
Overall Surgical Site Infections, 2017 Similar 0.74 Lower

‡ Each hospital is compared to the National Ratio=1 which is derived using the CDC's NHSN data from the 2015 baseline.

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

Higher - indicates hospital infections are HIGHER than infections seen nationally.

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