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Summary of Hospital Quality Measures

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Deborah Heart and Lung Center
http://www.deborah.org



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 7.7 5 5.8
Pneumonia 5.0 4.5 5.9
Heart Failure 2.6 2.6 2.8
Stroke M 7 7.3
-: hospital did not perform the procedure during the year in question; or it did less than 3 procedures (risk-adjusted rates are not computed when the denominator is less than 3).



Outcome of Care Measures: Coronary Artery Bypass Graft (CABG) Surgery Mortality
Lower Rate is Better
Hospital Rate State Rate
Number of Cases 396 8006
Mortality Rate* 0.18 1.80
95% Confidence Interval (0.00, 0.99)
* 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.

Significantly lower than the state average mortality based on 95 percent confidence interval.


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 0 629 10 NA
Iatrogenic pneumo thorax 0.1 0.2 89 0.2
In Hospital Fall with Hip Fracture 0 0.1 38 0.1
Post-operative hemorrhage or hematoma 2.4 2.4 313 2.2
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT) 2.6 3.4 551 3.7
Post-operative sepsis 7.2 4.1 215 3.8
Post-operative wound dehiscence 0 0.8 29 0.6
Abdominopelvic Accidental Puncture or Laceration 0 1.0 89 0.8
Birth Trauma+ . 4.5 221 2.4
Obstetric trauma - vaginal delivery with instrument+ . 116.0 429 114.7
Obstetric trauma - vaginal delivery without instrument+ . 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.

. (Missing) Hospital did not perform the procedure during the year; or it performed less than 3 procedures (rate is not calculated when the denominator is less than 3).




Healthcare Associated Infections (HAIs)
  Hospital to
National Comparison‡
Standardized Infection Ratio (SIR) NJ Statewide to
National Comparison
Catheter-Associated Urinary Tract Infections (CAUTI), 2019 Similar 0.29 Lower
Central Line-Associated Bloodstream Infections (CLABSI), 2019 Similar 0.526 Lower
Colon Surgical Site Infections, 2019 N/A --- Lower
Coronary Artery Bypass Graft (CABG) Infections, 2019 Similar 0.531 Similar
Overall Surgical Site Infections, 2019 Similar 0.531 Lower

Each hospital is compared to the National Ratio=1.

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

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


Cardiac Surgery Information and Reports
Outpatient measures for all hospitals [pdf 20k]
Healthcare Associated Infections (HAI) for all hospitals