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Summary of Hospital Quality Measures

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Morristown Memorial Hospital
http://www.atlantichealth.org/morristown/

Recommended Care/Process of Care Measures
Higher Score is Better
  Hospital
Overall Score		 State Median State Top 10%
Heart Attack (detail) 86 95 100
Pneumonia (detail) 97 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 (2013) Statewide Average Rate (2015)
Heart Attack 4.9 5.4 5.8
Pneumonia 2.6 3 3
Heart Failure 2.7 3.4 2.5
Stroke 8.2 7.9 7


Outcome of Care Measures: Coronary Artery Bypass Graft (CABG) Surgery Mortality
Lower Rate is Better
Hospital Rate State Rate
Number of Cases 643 3,881
Mortality Rate* 0.93 1.57
95% Confidence Interval (0.34, 2.02)
* 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 (2013) Statewide number of adverse events (2015) Statewide average rate (2015)
Retained Surgical Item or Unretrieved Device Fragment 0 852 23 -
Iatrogenic pneumo thorax 0.1 0.3 160 0.2
Post-operative hip fracture 0 0.1 3 0
Post-operative hemorrhage or hematoma 6.5 ** 4.5 791 4.4
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT) 4.8 3.7 1090 5.5
Post-operative sepsis 6.5 4.3 117 8.1
Post-operative wound dehiscence 0 1.7 37 1.2
Accidental puncture or laceration 0.8 0.7 611 1
Transfusion reaction 0 38 0 -
Birth Trauma+ 0.9 2 192 2
Obstetric trauma - vaginal delivery with instrument+ 156.8 127.9 328 96
Obstetric trauma - vaginal delivery without instrument+ 11.5 20 747 13.3

+ 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, 2014 Similar 1.141 Similar
Catheter-Associated Urinary Tract Infections (CAUTI), 2014 Higher 1.847 Higher
Central Line-Associated Bloodstream Infections (CLABSI), 2014 Lower 0.5 Lower
Colon Surgical Site Infections, 2014 Similar 0.214 Lower
Coronary Artery Bypass Graft (CABG) Infections, 2014 Lower 0.313 Similar
Knee Arthroplasty Surgical Site Infections, 2014 Similar 0 Lower
Overall Surgical Site Infections, 2014 Lower 0.269 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
Health System: Atlantic Health System
Outpatient measures for all hospitals [pdf 20k]
Healthcare Associated Infections (HAI) for all hospitals