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Summary of Hospital Quality Measures

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Saint Michael's Medical Center
http://www.smmcnj.org



Outcome of Care Measures: Inpatient Quality Indicator (IQI)
Lower Rate is Better
Hospital Rate National Average Rate (2019) Statewide Average Rate (2022)
Heart Attack 9.0 4.9 5.3
Pneumonia 2.7 4.3 4.6
Heart Failure 1.2 2.5 2.8
Stroke 0.0 6.7 6.8


Outcome of Care Measures: Coronary Artery Bypass Graft (CABG) Surgery Mortality
Lower Rate is Better
Hospital Rate State Rate
Number of Cases 67 7627
Mortality Rate* 1.75 2.18
95% Confidence Interval (0.02, 9.74)


* 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 comparative ratea (2019) Statewide number of adverse events (2022) Satewide average rates (2022)
Retained Surgical Item or Unretrieved Device Fragment 0 597 10 NA
Iatrogenic pneumo thorax 0.5 0.2 34 0.1
In Hospital Fall with Hip Fracture 0 0.1 24 0.1
Post-operative hemorrhage or hematoma 0 2.2 147 1.9
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT) 0 3.2 238 3
Post-operative sepsis 16.7 3.9 94 2.9
Post-operative wound dehiscence 0 1.6 30 1
Abdominopelvic Accidental Puncture or Laceration 0 1 64 1
Birth Trauma+ . 4.6 249 2.6
Obstetric trauma - vaginal delivery with instrument+ . 117.2 394 106.7
Obstetric trauma - vaginal delivery without instrument+ . 17.5 947 16.1

+ 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
Abdominal Hysterectomy Surgical Site Infections, 2022 --- --- Similar
Catheter-Associated Urinary Tract Infections (CAUTI), 2022 Higher 3.99 Lower
Central Line-Associated Bloodstream Infections (CLABSI), 2022 Higher 3.162 Lower
Colon Surgical Site Infections, 2022 --- --- Lower
Coronary Artery Bypass Graft (CABG) Infections, 2022 --- --- Similar
Knee Arthroplasty Surgical Site Infections, 2022 --- --- Similar
Overall Surgical Site Infections, 2022 Similar 0.816 Lower

Each hospital is compared to the National Ratio=1.

--- Standardized Infection Ratio (SIR) is not calculated because the Expected is < 1

Higher - áindicates hospital infections are HIGHER than infections seen nationally.

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: Catholic Health East NJ
Healthcare Associated Infections (HAI) for all hospitals