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Summary of Hospital Quality Measures

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St. Mary's General Hospital
http://www.smh-passaic.com

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) 97 99 100
Surgical Care Improvement (detail) 99 99 100
Heart Failure (detail) 99 100 100

^ 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 (2016) Statewide Average Rate (2018)
Heart Attack 3.3 5.1 5
Pneumonia 1.2 2.8 2.5
Heart Failure 0.0 2.7 2.7
Stroke 4.1 7.4 6


Outcome of Care Measures: Coronary Artery Bypass Graft (CABG) Surgery Mortality
Lower Rate is Better
Hospital Rate State Rate
Number of Cases 91 8,066
Mortality Rate* 1.81 1.76
95% Confidence Interval (0.02, 10.10)
* 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 averages (2016) Statewide number of adverse events (2018) Statewide average rates (2018)
Retained Surgical Item or Unretrieved Device Fragment 0 694 17 NA
Iatrogenic pneumo thorax 0 0.2 104 0.2
In Hospital Fall with Hip Fracture 0.2 0.1 29 0.1
Post-operative hemorrhage or hematoma 0 2.3 382 2.3
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT) 0 * 3.4 684 4
Post-operative sepsis 0 4 247 3.2
Post-operative wound dehiscence 0 0.7 27 0.6
Unrecognized Abdominopelvic Accidental Puncture or Laceration 0 1.1 93 0.8
Birth Trauma+ 2.1 4.6 225 2.4
Obstetric trauma - vaginal delivery with instrument+ 250^ 109.9 451 112.1
Obstetric trauma - vaginal delivery without instrument+ 8 17.3 842 14.4

+ 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.

* 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
Abdominal Hysterectomy Surgical Site Infections, 2018 --- 0 Similar
Catheter-Associated Urinary Tract Infections (CAUTI), 2018 Lower 0.2 Lower
Central Line-Associated Bloodstream Infections (CLABSI), 2018 Similar 0.81 Lower
Colon Surgical Site Infections, 2018 --- 0 Lower
Coronary Artery Bypass Graft (CABG) Infections, 2018 --- 0 Similar
Knee Arthroplasty Surgical Site Infections, 2018 --- 0 Similar
Overall Surgical Site Infections, 2018 Similar 0.7 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