Hospital Performance Report

Summary of Hospital Quality Measures

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Hackensack University Medical Center
http://www.hackensackumc.org/

Outcome of Care Measures: Mortality Inpatient Quality Indicator (IQI) Lower Rate is Better
	Hospital Rate	National Average Rate (2019)	Statewide Average Rate (2021)
Heart Attack	4.5	4.9	5.6
Pneumonia	3.2	4.3	5.3
Heart Failure	2.3	2.5	3
Stroke	7.0	6.7	6.9

Outcome of Care Measures: Coronary Artery Bypass Graft (CABG) Surgery Mortality Lower Rate is Better
	Hospital Rate	State Rate
Number of Cases	708	7398
Mortality Rate*	1.04	2.37
95% Confidence Interval	(0.45, 2.04)
* 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 ratea (2019)	Statewide number of adverse events (2021)	Satewide average rates (2021)
Retained Surgical Item or Unretrieved Device Fragment	2	597	11	NA
Iatrogenic pneumo thorax	0	0.2	75	0.1
In Hospital Fall with Hip Fracture	0	0.1	40	0.1
Post-operative hemorrhage or hematoma	1.8	2.2	326	2.2
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT)	1.3 *	3.2	512	3.3
Post-operative sepsis	3.6	3.9	225	3.8
Post-operative wound dehiscence	1.3	1.6	29	0.9
Abdominopelvic Accidental Puncture or Laceration	0.6	1	111	1
Birth Trauma+	5.3	4.6	296	3.2
Obstetric trauma - vaginal delivery with instrument+	95.4	117.2	401	106.4
Obstetric trauma - vaginal delivery without instrument+	12.7	17.5	942	15.8
+ 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. * Better than State Average (i.e.occurrence rate of adverse events is less than statewide rate).

Healthcare Associated Infections (HAIs)
	Hospital to National Comparison‡	Standardized Infection Ratio (SIR)	NJ Statewide to National Comparison
Abdominal Hysterectomy Surgical Site Infections, 2019	Similar	0.482	Similar
Catheter-Associated Urinary Tract Infections (CAUTI), 2019	Similar	0.996	Lower
Central Line-Associated Bloodstream Infections (CLABSI), 2019	Similar	0.8	Lower
Colon Surgical Site Infections, 2019	Similar	0.923	Lower
Coronary Artery Bypass Graft (CABG) Infections, 2019	Similar	0.494	Similar
Knee Arthroplasty Surgical Site Infections, 2019	Similar	0.267	Similar
Overall Surgical Site Infections, 2019	Similar	0.631	Lower
Each hospital is compared to the National Ratio=1. Lower - indicates hospital infections are LOWER than infections seen nationally. Similar - áindicates hospital infections are SIMILAR to infections seen nationally.

Cardiac Surgery Information and Reports

Health System: Hackensack Meridian Health

Outpatient measures for all hospitals [pdf 20k]

Healthcare Associated Infections (HAI) for all hospitals