Outcomes measures include errors, accidents, and injuries that this hospital has publicly reported.
| Dangerous object left in patient’s body
What's This?
Dangerous object left in patient’s body A surgeon can accidentally leave an object inside a patient’s body during surgery. Most times the object is a surgical sponge, which can quickly get infected. This problem doesn’t happen often, but if it does happen it can be extremely dangerous. Many patients become severely ill, disabled, or even die. This number represents the number of times dangerous objects were left inside patients for every 1,000 people discharged.
|
0.000 |
0.336 |
0.014 |
0.000 |
CMS |
07/01/2020 - 06/30/2022 |
| Air or gas bubble in the blood
What's This?
Air or gas bubble in the blood An air or gas bubble (air embolism) stops blood from flowing through the body. This serious mistake can happen during surgery or other procedures, like getting an injection. If blood flow is blocked, a patient can suffer a stroke or die. This number represents the number of times patients had an air or gas bubble in the blood for every 1,000 people discharged.
|
0.000 |
0.308 |
0.001 |
0.000 |
CMS |
07/01/2020 - 06/30/2022 |
| Patient falls and injuries
What's This?
Patient falls and injuries One common problem that patients face in the hospital is a serious injury or death resulting from a fall or other kind of trauma. Falls can happen when patients who really can’t walk on their own try getting out of bed, often to go to the restroom. Patient falls and injuries increase time in the hospital, require additional care, and can result in permanent disability. This number represents the number of times patients experienced falls or other types of trauma for every 1,000 people discharged.
|
0.484 |
2.006 |
0.428 |
0.000 |
CMS |
07/01/2020 - 06/30/2022 |
| Infection in the blood
What's This?
Infection in the blood If a patient is in the hospital, he or she may be given a central line (a tube inserted into the body to deliver medication and other treatments). Patients with a central line are at high risk for developing a dangerous infection in the blood. These serious infections can lead to other complications, increase recovery time, and can often lead to death. This number represents a comparison of the number of central line-associated infections in the blood that actually happened at this hospital to the number of infections expected for this hospital, given the number of central lines used and other factors like facility type and size. A number lower than one means fewer infections than expected; a number more than one means more infections than expected.
|
1.376 |
2.944 |
0.730 |
0.000 |
CMS |
04/01/2022 - 03/31/2023 |
| Infection in the urinary tract
What's This?
Infection in the urinary tract If a patient is in the hospital, he or she may require a urinary catheter. Patients with catheters are at risk for developing a dangerous infection in the urinary tract. These serious infections can lead to other complications, increase recovery time, and can often lead to death. This number represents a comparison of the number of catheter-associated infections in the urinary tract that actually happened at this hospital to the number of infections expected for this hospital, given the number of catheters used and other factors like facility type and size. A number lower than one means fewer infections than expected; a number more than one means more infections than expected.
|
0.996 |
2.482 |
0.627 |
0.000 |
CMS |
04/01/2022 - 03/31/2023 |
| Surgical site infection after colon surgery
What's This?
Surgical site infection after colon surgery This infection happens after surgery in the part of the colon where the surgery took place. These infections can be very serious, and may spread throughout the body. A patient with this type of infection often faces a long recovery in the ICU. Some people even die from the infection. This number represents a comparison of the number of infections after colon surgery that actually happened at this hospital to the number of infections expected for this hospital, given the types of patients they care for and other factors like a patient’s age and type of surgery. A number lower than one means fewer infections than expected; a number more than one means more infections than expected.
|
1.009 |
3.207 |
0.845 |
0.000 |
CMS |
04/01/2022 - 03/31/2023 |
| MRSA Infection
What's This?
MRSA infection Staph bacteria are common in hospitals, but Methicillin-resistant Staphylococcus aureus (MRSA) is a type of staph bacteria that is resistant to (cannot be killed by) many antibiotics. MRSA can be found in bed linens or medical equipment and can be spread if providers do not properly wash their hands between patients. MRSA can cause life-threatening bloodstream infections, pneumonia and surgical site infections. This number represents a comparison of the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given the number of patients they care for on a daily basis and how widespread MRSA infection is in their local community. A number lower than one means fewer infections than expected; a number more than one means more infections than expected.
|
2.357 |
2.908 |
0.793 |
0.000 |
CMS |
04/01/2022 - 03/31/2023 |
| C. diff. Infection
What's This?
C. diff infection Clostridium difficile (C. diff) is a bacterium that can cause diarrhea, abdominal pain, loss of appetite, and fever. Most C. diff cases occur in patients taking or having recently taken antibiotics, and fully killing the bacteria in an infected patient can be very difficult. C. diff can spread via contaminated equipment or by providers who fail to properly wash their hands between patients. This number represents a comparison of the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given the number of patients they care for on a daily basis and how widespread C. diff infection is in their local community. A number lower than one means fewer infections than expected; a number more than one means more infections than expected.
|
0.460 |
1.791 |
0.455 |
0.000 |
CMS |
04/01/2022 - 03/31/2023 |
| Death from treatable serious complications
What's This?
Death from treatable serious complications Sometimes after surgery, patients can develop serious complications while they are in the hospital. They might catch pneumonia, have a heart attack, or lose function in their kidneys or liver. These problems are serious but can be treated by a good hospital team. If the hospital doesn’t manage the patient’s complications correctly, the patient could die. This number represents the number of surgical patients that died for every 1,000 people who had a serious treatable complication after surgery.
|
192.78 |
222.70 |
168.38 |
86.68 |
CMS |
07/01/2020 - 6/30/2022 |
|
Harmful Events
What's This?
Harmful Events
Patients can experience complications and potentially harmful events following a surgery , a procedure, or childbirth. . When all of these errors are examined together, it gives a better picture of a hospital’s ability to keep its patients safe.
This number represents the number of times patients experienced dangerous safety-related adverse events for every 1,000 people discharged.
|
1.15 |
2.74 |
1.01 |
0.55 |
CMS |
07/01/2020 - 6/30/2022 |
| Dangerous bed sores
What's This? *
Dangerous bed sores A bed sore is a sore or wound on the skin that forms when a patient lays or sits in one position for too long without being moved. Advanced bedsores (also known as stage 3 or 4 pressure ulcers) can become large and very deep. They can reach a muscle or bone and cause severe pain and serious infection. This can lead to longer hospital stays, amputation, or even death. This number represents the number of times patients experienced dangerous bed sores for every 1,000 people discharged.
|
0.20 |
6.31 |
0.58 |
0.05 |
CMS |
07/01/2020 - 6/30/2022 |
| Collapsed lung
What's This? *
Collapsed lung A collapsed lung is when air leaks out of the lung and goes into the area between the lungs and the chest wall. It can happen when a doctor or nurse is inserting a catheter, a feeding tube, or even a pacemaker. This kind of lung injury can be serious and can cause severe chest pain and other complications. This number represents the number of times patients experienced collapsed lungs for every 1,000 people discharged.
|
0.21 |
0.51 |
0.25 |
0.12 |
CMS |
07/01/2020 - 6/30/2022 |
|
Falls causing broken hips
What's This? *
Falls causing broken hips
Patients in the hospital, especially those who are older or have weaker bones, are at risk of breaking their hip if they fall. Broken hips can delay a patient’s recovery time, require longer hospital stays, and cause depression when patients lose their ability to move.
This number represents the number of times patients experienced hip fractures for every 1,000 people discharged.
|
0.11 |
0.13 |
0.09 |
0.06 |
CMS |
07/01/2020 - 6/30/2022 |
|
Blood Leakage
What's This? *
Blood Leakage
If blood vessels become injured during surgery, they may leak excess blood within the body. In some cases, the blood leak will clump up or clot. In other cases, the blood leak is active and ongoing. Both blood clots and internal bleeding can cause significant damage to the body’s organs, potentially leading to organ failure or even death.
This number represents the estimated number of times patients experienced blood leakage during a procedure for every 1,000 people who had surgery.
|
2.85 |
6.10 |
2.50 |
1.10 |
CMS |
07/01/2020 - 6/30/2022 |
|
Kidney injury after surgery
What's This? *
Kidney injury after surgery
After major surgery, particularly heart surgery, some patients may experience kidney failure. In serious cases, kidney failure can lead to the need for dialysis, an artificial way of replacing the kidneys’ function. In the most extreme cases, a patient may need a kidney transplant or risk death. Patients who are older or have other pre-existing health problems are at a greater risk of experiencing kidney failure.
This number represents the estimated number of times patients experienced kidney failure for every 1,000 people who had surgery.
|
2.10 |
4.55 |
1.57 |
0.47 |
CMS |
07/01/2020 - 6/30/2022 |
| Serious breathing problem
What's This? *
Serious breathing problem After surgery some patients can develop a serious breathing problem. Their lungs either cannot take in enough oxygen or cannot get rid of carbon dioxide. Without immediate care, the patient can lose consciousness, fall into a coma, or even die. This number represents the number of times patients experienced serious breathing problems for every 1,000 people who had surgery.
|
16.27 |
49.00 |
9.19 |
2.73 |
CMS |
07/01/2020 - 6/30/2022 |
| Dangerous blood clot
What's This? *
Dangerous blood clot A blood clot is a gathering of blood cells in a vein, which can be caused by damage to tissue during surgery. Most blood clots form in the leg but the clot can break away and travel through the bloodstream to other areas of the body. If the clot travels to the lungs and gets stuck, it can prevent oxygen from getting into the blood. This can lead to chest pain, unconsciousness, and even death. This number represents the number of times patients experienced dangerous blood clots for every 1,000 people who had surgery.
|
3.37 |
7.51 |
3.61 |
1.61 |
CMS |
07/01/2020 - 6/30/2022 |
|
Sepsis infection after surgery
What's This? *
Sepsis infection after surgery
Sepsis is your body’s extreme reaction to an infection. All types of surgeries can put a patient at risk of infection that can lead to sepsis. This could be infection where the skin was cut, or an infection that develops after the surgery, like pneumonia. Sepsis requires immediate treatment or the patient may experience lifelong complications including organ failure. Some patients may die if sepsis is not treated quickly.
This number represents the number of surgical patients that experienced a sepsis infection for every 1,000 people who had surgery.
|
5.96 |
13.49 |
5.33 |
2.17 |
CMS |
07/01/2020 - 6/30/2022 |
| Surgical wound splits open
What's This? *
Surgical wound splits open After a major surgery on the stomach or abdomen area, the healthcare team must be careful to make sure that the surgical stitches don’t break open. This could leave the wound exposed. A surgical wound splitting open is very painful and puts the patient at risk for infection. This number represents the number of times surgical wounds in the stomach or abdomen area split open for every 1,000 people who had surgery on their abdomen.
|
1.75 |
4.40 |
2.01 |
0.89 |
CMS |
07/01/2020 - 6/30/2022 |
| Accidental cuts and tears
What's This? *
Accidental cuts and tears For procedures of the abdomen and pelvis, there is a chance that the patient will suffer an accidental cut or tear of their skin or other tissue. This problem can happen during surgery or a procedure where doctors use a tube to look into a patient’s body. This number represents the number of times patients experienced accidental cuts and tears in the abdominal or pelvic region during a procedure for every 1,000 people discharged.
|
1.04 |
3.43 |
1.10 |
0.35 |
CMS |
07/01/2020 - 6/30/2022 |
| * This measure is a part of the Harmful Events Composite and is not used for scoring. |
Process measures include the management structures and procedures a hospital has in place to protect patients from errors, accidents, and injuries.
| Measure |
The Hospital's Score |
Worst Performing Hospital |
Avg. Performing Hospital |
Best Performing Hospital |
Data Source |
Time Period Covered |
| Doctors order medications through a computer
What's This?
Doctors order medications through a computer Hospitals can use Computerized Physician Order Entry (CPOE) systems to order medications for patients in the hospital, instead of writing out prescriptions by hand. Good CPOE systems alert the doctor if they try to order a medication that could cause harm, such as prescribing an adult dosage for a child. CPOE systems help to reduce medication errors in the hospital. Hospitals can earn up to 100 points for using a well-functioning CPOE system in most areas of the hospital.
|
79 |
15 |
91.81 |
100 |
Imputation Model Applied |
Not Applicable |
| Safe medication administration
What's This?
Safe medication administration Using barcodes on medications, nurses can scan the medication and then the patient’s ID bracelet to make sure the patient is receiving the right medications. If the bar codes do not match, this signals there is an error, giving nurses and doctors the chance to confirm they have the right patient, right medication, and right dose. Bar code medication administration (BCMA) systems are proven to reduce the risk that a hospital accidentally gives the wrong medication to a patient. Hospitals earn up to 100 points for using a well-functioning bar coding system for all medication orders, and making sure it is used properly to keep patients safe.
|
82 |
25 |
93.42 |
100 |
Imputation Model Applied |
Not Applicable |
| Specially trained doctors care for ICU patients
What's This?
Specially trained doctors care for ICU patients A critical care unit or Intensive Care Unit (ICU) is a special part of the hospital that provides care for extremely ill patients. Hospitals should have special doctors called intensivists working in the ICU. Intensivists are physicians with advanced training in intensive or critical care. They learn to manage problems in the ICU and help to reduce errors. There are higher death rates in hospitals where ICU patients are not cared for by intensivists. Hospitals can earn up to 100 points for staffing their ICUs with intensivists.
|
5 |
5 |
63.29 |
100 |
CMS Cost Report |
Not Applicable |
| Effective leadership to prevent errors
What's This?
Effective leadership to prevent errors Errors are much more common if hospital leaders don’t make patient safety a priority. Leaders must make sure that all hospital staff knows what they need to work on and that they are held accountable for improvements. The hospital should also budget money towards improving safety. Hospitals can earn up to 120 points for having leadership structures that increase awareness of patient safety issues and holding leadership accountable for improvements.
|
Declined to Report |
64.62 |
117.59 |
120.00 |
2023 Leapfrog Hospital Survey |
2023 |
| Staff work together to prevent errors
What's This?
Staff work together to prevent errors A hospital that has a strong culture of safety has a well-functioning team with good leaders who catch errors before they can harm a patient. Patients are less likely to experience mistakes if hospital staff works together. Staff should also be comfortable speaking up when they sense an error might happen. Hospitals can earn up to 120 points for measuring culture of safety, providing feedback to staff, and creating new plans to prevent errors.
|
Declined to Report |
0.00 |
117.08 |
120.00 |
2023 Leapfrog Hospital Survey |
2023 |
| Nursing and Bedside Care for Patients
What's This?
Nursing and Bedside Care for PatientsStudies show better staffing practices have a meaningful impact on the quality and safety of patient care. When hospitals have more nurses and assistive personnel, patients are more likely to have better experiences and improved health outcomes. Without enough nurses, patients might face complications, longer hospital stays, and even death. Hospitals can earn up to 100 points for this measure for staffing their hospitals with enough nurses (RNs), licensed practical nurses (LPNs), and unlicensed assistive personnel (UAPs).
|
Declined to Report |
15 |
74.69 |
100 |
2023 Leapfrog Hospital Survey |
2023 |
| Handwashing
What's This?
Handwashing Healthcare workers can help stop infection and illness by carefully cleaning their hands. When hospital staff does not carefully wash their hands, they can spread germs from one patient to another and cause someone to become seriously ill. Hospitals can earn up to 100 points for having a handwashing policy and evaluating how hospital workers follow that policy.
|
52 |
15 |
78.65 |
100 |
Imputation Model Applied |
Not Applicable |
| Communication with nurses
What's This?
Communication with nurses Patients’ perspectives of care are an important part of patient safety. The Communication with Nurses measure summarizes how well patients feel that their nurses explained things clearly, listened carefully to them, and treated them with courtesy and respect. Effective communication between nurses and patients can be reassuring to patients and can prevent errors like medication mix-ups or misdiagnoses. Based on a scale of zero-100, this number represents a comparison of patients’ perspectives of how effectively nurses at this hospital communicated with patients relative to patients’ perspectives of how effectively nurses at other hospitals communicated with their patients. Higher scores indicate more effective communication than lower scores.
|
91 |
77 |
89.67 |
96 |
CMS |
04/01/2022 - 03/31/2023 |
| Communication with doctors
What's This?
Communication with doctors Patients’ perspectives of care are an important part of patient safety. The Communication with Doctors measure summarizes how well patients feel their doctors explained things clearly, listened carefully to them, and treated them with courtesy and respect. Effective communication between doctors and patients can be reassuring to patients and can help prevent errors like medication mix-ups or misdiagnoses. Based on a scale of zero-100, this number represents a comparison of patients’ perspectives of how effectively physicians at this hospital communicated with patients relative to patients’ perspectives of how effectively physicians at other hospitals communicated with their patients. Higher scores indicate more effective communication than lower scores.
|
90 |
77 |
89.52 |
98 |
CMS |
04/01/2022 - 03/31/2023 |
| Responsiveness of hospital staff
What's This?
Responsiveness of hospital staff Patients’ perspectives of care are an important part of patient safety. The Responsiveness of Hospital Staff measure looks at patients’ feedback on how long it takes for a staff member to respond when they request help. If a patient is in pain, experiencing new symptoms, or cannot reach the bathroom himself, it is important that hospital staff respond quickly to address the situation. Based on a scale of zero-100, this number represents a comparison of patients’ perspectives of how quickly the staff at this hospital typically responds to patients’ requests for help relative to patients’ perspectives of how quickly the staff at other hospitals typically respond to their patients’ requests. Higher scores indicate a faster response time than lower scores.
|
83 |
61 |
81.14 |
94 |
CMS |
04/01/2022 - 03/31/2023 |
| Communication about medicines
What's This?
Communication about medicines Patients’ perspectives of care are an important part of patient safety. The Communication about Medicines measure reflects patients’ feedback on how often hospital staff explained the purpose of any new medicine and what side effects that medicine might have. Effective communication about medicine prevents misunderstandings that could lead to serious problems for a patient. Based on a scale of zero-100, this number represents a comparison of patients’ perspectives of how effectively this hospital communicated with patients about their medications relative to patients’ perspectives of how effectively other hospitals communicated with their patients. Higher scores indicate more effective communication than lower scores.
|
72 |
56 |
74.09 |
91 |
CMS |
04/01/2022 - 03/31/2023 |
| Communication about discharge
What's This?
Communication about discharge Patients’ perspectives of care are an important part of patient safety. The Communication about Discharge measure summarizes how well the hospital staff communicated with patients about the help they would need at home after leaving the hospital. The measure also summarizes how often patients reported that they were given written information about symptoms or health problems to watch for during their recovery. Educating patients on the steps they need to take during their recovery at home reduces the chances that a patient will need to be readmitted to the hospital. Based on a scale of zero-100, this number represents a comparison of patients’ perspectives of how effectively this hospital communicated with patients about the help they would need after discharge relative to patients’ perspectives of how effectively other hospitals communicated with their patients. Higher scores indicate more effective communication than lower scores.
|
84 |
63 |
84.90 |
94 |
CMS |
04/01/2022 - 03/31/2023 |
