Hospital Performance Report

Summary of Hospital Quality Measures

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Southern Ocean Medical Center
http://www.meridianhealth.com

Hospital is not licensed to perform CABG surgery.

Outcome of Care Measures: Mortality Inpatient Quality Indicator (IQI) Lower Rate is Better
	Hospital Rate	National Average Rate (2018)	Statewide Average Rate (2020)
Heart Attack	10.3 ^ **	5	5.8
Pneumonia	4.0	4.5	5.9
Heart Failure	1.6	2.6	2.8
Stroke	3.7	7	7.3
** Statistically significantly above statewide average (worse than average) ^ Rate is based on denominator less than 30 and should be taken with caution

Patient Safety Indicators Lower Rate is Better
	Hospital Rate	National comparative rates (2018)	Statewide number of adverse events (2020)	Statewide average rates (2020)
Retained Surgical Item or Unretrieved Device Fragment	1	629	10	NA
Iatrogenic pneumo thorax	0	0.2	89	0.2
In Hospital Fall with Hip Fracture	0	0.1	38	0.1
Post-operative hemorrhage or hematoma	2	2.4	313	2.2
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT)	3.3	3.4	551	3.7
Post-operative sepsis	0	4.1	215	3.8
Post-operative wound dehiscence	1.8	0.8	29	0.6
Abdominopelvic Accidental Puncture or Laceration	0.9	1.0	89	0.8
Birth Trauma+	6	4.5	221	2.4
Obstetric trauma - vaginal delivery with instrument+	153.8^	116.0	429	114.7
Obstetric trauma - vaginal delivery without instrument+	32.3	17.4	832	14.8
+ 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. ^ 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, 2019	---	---	Similar
Catheter-Associated Urinary Tract Infections (CAUTI), 2019	Similar	0.727	Lower
Central Line-Associated Bloodstream Infections (CLABSI), 2019	Similar	0.543	Lower
Colon Surgical Site Infections, 2019	Similar	0.74	Lower
Knee Arthroplasty Surgical Site Infections, 2019	---	---	Similar
Overall Surgical Site Infections, 2019	Similar	0.533	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 - áindicates hospital infections are SIMILAR to infections seen nationally.

Health System: Hackensack Meridian Health

Outpatient measures for all hospitals [pdf 20k]

Healthcare Associated Infections (HAI) for all hospitals