Acute Care
Saint Mary's Regional Medical Center
Emergency Care
Hospital Compare, Centers for Medicare and Medicaid Services (CMS)
| Measure |
Rate |
State Avg. |
National Avg. |
|
Left ED Without Being Seen
|
1%
|
1% |
2% |
|
Minutes in ED Before Going Home
|
152
|
143 |
163 |
Readmissions
Hospital Compare, Centers for Medicare and Medicaid Services (CMS)
| Measure |
Rate |
State Avg. |
National Avg. |
|
Chronic Obstructive Pulmonary Disease (COPD) 30-Day Readmission Rate
|
17.9%
|
Not Applicable |
No different than the National Rate18.5% |
|
Coronary Artery Bypass Graft (CABG) Surgery 30-Day Readmission Rate
|
10.5%
|
Not Applicable |
No different than the National Rate10.7% |
|
Heart Attack Readmit
|
12.6%
|
Not Applicable |
No different than the National Rate13.7% |
|
Heart Failure 30-Day Readmission Rate
|
19.4%
|
Not Applicable |
No different than the National Rate19.8% |
|
Hip and Knee 30-Day Readmission Rate
|
4.6%
|
Not Applicable |
No different than the National Rate4.5% |
|
Hospital-wide 30-Day Readmission Rate
|
14.8%
|
Not Applicable |
No different than the National Rate14.6% |
|
Pneumonia 30-Day Readmission Rate
|
16.8%
|
Not Applicable |
No different than the National Rate16.4% |
|
Patients readmitted to any hospital within 30 days of discharge from the inpatient psychiatric facility
|
20.4%
|
Not Applicable |
No different than the National Rate19.4% |
Mortality CMS
Hospital Compare, Centers for Medicare and Medicaid Services (CMS)
| Measure |
Rate |
State Avg. |
National Avg. |
|
COPD 30-Day Mortality Rate
|
9.5%
|
Not Applicable |
No different than the National RateNot Applicable |
|
Coronary Artery Bypass Graft (CABG) Surgery 30-Day Mortality Rate
|
3%
|
Not Applicable |
No different than the National RateNot Applicable |
|
Heart Attack 30-Day Mortality Rate
|
11.6%
|
Not Applicable |
No different than the National RateNot Applicable |
|
Heart Failure 30-Day Mortality Rate
|
12%
|
Not Applicable |
No different than the National RateNot Applicable |
|
Pneumonia 30-Day Mortality Rate
|
15.5%
|
Not Applicable |
No different than the National RateNot Applicable |
|
Stroke 30-Day Mortality Rate
|
14.4%
|
Not Applicable |
No different than the National RateNot Applicable |
Mortality AHRQ
Agency for Healthcare Research & Quality Quality Indicators (AHRQ)
| Measure |
Rate |
Relative to State |
Relative to National |
|
Acute Myocardial Infarction (AMI) Mortality Rate
|
0.0535
|
Average compared to State Mean0.063 |
Average compared to National Mean0.0501 |
|
Acute Stroke Mortality Rate
|
0.0715
|
Average compared to State Mean0.072 |
Average compared to National Mean0.0722 |
|
Death Rate Among Surgical Inpatients With Serious Treatable Complications
|
0.1451
|
Average compared to State MeanNot Applicable |
Average compared to National Mean17 |
|
Heart Failure Mortality Rate
|
0.0191
|
Average compared to State Mean0.021 |
Average compared to National Mean0.0272 |
|
Hip Fracture Mortality Rate
|
7.0602
|
0.019 |
Below National Mean0.0204 |
|
Pneumonia Mortality Rate
|
0.0207
|
Average compared to State Mean0.023 |
Average compared to National Mean0.026 |
Adverse Event
Agency for Healthcare Research & Quality Quality Indicators (AHRQ)
| Measure |
Rate |
Relative to State |
Relative to National |
|
Accidental Puncture or Laceration Rate
|
0.9614
|
Not Applicable |
Better than National MeanNot Applicable |
|
Birth Trauma - Injury to Neonate
|
0.0054
|
Better than State Mean0.002 |
Better than National MeanNot Applicable |
|
Obstetric Trauma Rate - Vaginal Delivery With Instrument
|
8
|
Better than State Mean131 |
Not Applicable |
|
Obstetric Trauma Rate - Vaginal Delivery Without Instrument
|
19
|
Better than State Mean340 |
Not Applicable |
Immunizations
| Measure |
Rate |
State Avg. |
National Avg. |
|
Health Care Worker Flu Immunization
|
86%
|
66% |
80% |
|
Influenza immunization (IPFQR-IMM-2)
|
87%
|
68% |
76% |
|
Percentage of healthcare personnel who completed COVID-19 primary vaccination series
|
1.5%
|
11.1% |
12.4% |
|
Percentage of healthcare personnel who completed COVID-19 primary vaccination series (IPFQR-HCP COVID-19)
|
0%
|
5.6% |
14.2% |
Postoperative Complication
Agency for Healthcare Research & Quality Quality Indicators (AHRQ)
| Measure |
Rate |
Relative to State |
Relative to National |
|
Postoperative Hemorrhage or Hematoma Rate
|
0.0025
|
Average compared to State MeanNot Applicable |
Average compared to National MeanNot Applicable |
|
Postoperative Respiratory Failure Rate
|
3.4645
|
Not Applicable |
Better than National Mean1 |
Infections
Infection measures are reported in relation to the national benchmark.
N/C
Not calculated:
Too few events
| Measure |
Rate |
Relative to State |
Relative to National |
|
Catheter-Associated Urinary Tract Infections
|
|
0.369 |
1 |
|
Central Line Bloodstream Infection
|
|
0.615 |
1 |
|
Colon Surgery Infection
|
|
0.779 |
1 |
|
MRSA Infection
|
|
0.712 |
1 |
|
Clostridium Difficile Infection (CDI)
|
|
0.240 |
Better than the National Benchmark1 |
Patient Satisfaction
| Measure |
Stars |
|
Doctor Communication
|
|
|
Overall Satisfaction Rating
|
|
|
Patients Recommend
|
|
|
Provided Discharge Instructions
|
|
|
Quiet at Night
|
|
|
Room Cleanliness
|
|
|
Staff Explained Medicine
|
|
|
Nurse Communication
|
|
|
Staff Responsiveness
|
|
|
Care Transition
|
|
|
Summary Star Rating
|
|
Substance Use Disorders
| Measure |
Rate |
Relative to State |
Relative to National |
|
Alcohol use brief intervention provided or offered
|
100%
|
35% |
58% |
|
Alcohol use brief intervention provided or offered
|
98%
|
77% |
76% |
|
Alcohol and other drug use disorder treatment provided or offered at discharge
|
100%
|
60% |
71% |
|
Alcohol and other drug use disorder treatment provided or offered at discharge
|
100%
|
55% |
59% |
|
Tobacco use treatment provided or offered at discharge
|
92%
|
36% |
56% |
|
Tobacco use treatment provided or offered at discharge
|
92%
|
11% |
16% |
Patient Safety
| Measure |
Rate |
Relative to State |
Relative to National |
|
Percent of patients receiving follow-up care within 30 days after hospitalization for mental illness
|
48.2%
|
47.8% |
59.5% |
|
Percent of patients receiving follow-up care within 7 days after hospitalization for mental illness
|
20.5%
|
26.6% |
35.7% |
