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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: Inpatient Quality Indicator (IQI)
Lower Rate is Better
Hospital Rate National Average Rate (2019) Statewide Average Rate (2022)
Heart Attack 5.8 4.9 5.3
Pneumonia 2.5 4.3 4.6
Heart Failure 2.5 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 324 7627
Mortality Rate* 0.92 2.18
95% Confidence Interval (0.25, 2.36)


* 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 0.2 34 0.1
In Hospital Fall with Hip Fracture 0 0.1 24 0.1
Post-operative hemorrhage or hematoma 3 2.2 147 1.9
Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT) 2.9 3.2 238 3
Post-operative sepsis 8.5 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).

^ Rate is based on less than 30 cases/patients and should be taken with caution.



Healthcare Associated Infections (HAIs)
  Hospital to
National Comparison‡		 Standardized Infection Ratio (SIR) NJ Statewide to
National Comparison
Abdominal Hysterectomy Surgical Site Infections, 2022 N/A --- Similar
Catheter-Associated Urinary Tract Infections (CAUTI), 2022 Lower 0 Lower
Central Line-Associated Bloodstream Infections (CLABSI), 2022 Similar 0.384 Lower
Colon Surgical Site Infections, 2022 N/A --- Lower
Coronary Artery Bypass Graft (CABG) Infections, 2022 Similar 0.612 Similar
Knee Arthroplasty Surgical Site Infections, 2022 N/A --- Similar
Overall Surgical Site Infections, 2022 Similar 0.612 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
Healthcare Associated Infections (HAI) for all hospitals