Delaware Hospital Guide - A public service of the Delaware Healthcare Association

Quality Measures

Quality Measurements as reported on Hospital Compare / Definitions
Note that measures for systems have been consolidated for member hospitals.
Data are for the collection period beginning 07/01/2009 to 06/30/2010 and posted on 04/20/2011
This report is based on information from Hospital Compare, a website created through the efforts of the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS) along with the Hospital Quality Alliance (HQA). The HQA is a public-private collaboration established to promote reporting on hospital quality of care.
Data are consolidated for all hospitals in the Bayhealth Medical Center system: Kent General Hospital, Milford Memorial Hospital.
System Name: Bayhealth Medical Center
Milford Memorial Hospital
21 West Clarke Avenue
Milford, DE 19963
(302) 422-3311

Click here for information about the Measures and Conditions reported.
 
Condition: Heart Attack
Measure Number Patients Hospital Footnotes Hospital Score National Average Nat 90th Percentile State Average
AMI-1. Aspirin at Arrival  329    99%  99%  100%  99%
AMI-2. Aspirin at Discharge  341    100%  98%  100%  99%
AMI-3. ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)  49    94%  96%  100%  95%
AMI-4. Smoking Cessation Advice/Counseling  139    99%  99%  100%  100%
AMI-5. Beta Blocker at Discharge  335    99%  98%  100%  98%
AMI-7a. Fibrinolytic Medication Within 30 Minutes Of Arrival  0    N/A  55%  100%  67%
AMI-8a. PCI Within 90 Minutes Of Arrival  53    91%  90%  100%  90%

Condition: Heart Failure
Measure Number Patients Hospital Footnotes Hospital Score National Average Nat 90th Percentile State Average
HF-1. Discharge Instructions  416    95%  88%  100%  92%
HF-2. Evaluation of Left Ventricular Systolic (LVS) Function  506    100%  98%  100%  99%
HF-3. ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)  171    99%  94%  100%  94%
HF-4. Smoking Cessation Advice/Counseling  123    100%  98%  100%  100%

Condition: Emergency Department: AMI Cardiac Care
Measure Number Patients Hospital Footnotes Hospital Score National Average Nat 90th Percentile State Average
OP-2. Fibrinolytic Therapy received within 30 minutes  0  3  N/A  54%  100%  0%
OP-3b. Median Time to transfer patients for Acute Coronary Intervention  5  1, 3  72 minutes  61 minutes  40 minutes  72 minutes
OP-4. Aspirin at Arrival  31     100%  95%  100%  100%
OP-5. Median Time to ECG  32     6 minutes  8 minutes  3 minutes  6 minutes

Condition: Emergency Department: Surgical Care
Measure Number Patients Hospital Footnotes Hospital Score National Average Nat 90th Percentile State Average
OP-6. Timing of Antibiotic Prophylaxis  211     83%  92%  99%  90%
OP-7. Prophylactic Antiobiotic Selection  200     84%  94%  100%  87%

Condition: Pneumonia
Measure Number Patients Hospital Footnotes Hospital Score National Average Nat 90th Percentile State Average
PN-2. Pneumococcal Vaccination Status  449    95%  93%  100%  91%
PN-3b. Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospita  488    95%  96%  100%  94%
PN-4. Smoking Cessation Advice/Counseling  261    99%  97%  100%  100%
PN-5c. Initial Antibiotic(s) within 6 Hours After Arrival  497    93%  95%  100%  94%
PN-6. Appropriate Initial Antibiotic Selection  303    90%  92%  99%  90%
PN-7. Influenza Vaccination Status  357    93%  91%  100%  87%

Condition: Surgical Care Improvement
Measure Number Patients Hospital Footnotes Hospital Score National Average Nat 90th Percentile State Average
SCIP-CARD-2. Patients on beta blocker at admission who received beta blocker during perioperative period  414  2  88%  93%  100%  95%
SCIP-INF-1. Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision  886  2  96%  97%  100%  97%
SCIP-INF-2. Prophylactic Antibiotic Selection  893  2  98%  97%  100%  99%
SCIP-INF-3. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time  808  2  95%  94%  100%  97%
SCIP-INF-4. Blood glucose controlled in days following heart surgery  158  2  99%  93%  99%  94%
SCIP-INF-6. Safe method of hair removal from surgical site used when needed  1203  2  100%  99%  100%  100%
SCIP-INF-9. Urinary catheter removed within two days following surgery  220  2  93%  90%  100%  95%
SCIP-VTE-1. Recommended Venous Thromboembolism Prophylaxis Ordered  329  2  95%  94%  100%  96%
SCIP-VTE-2. Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery  329  2  88%  92%  100%  93%

Condition: Children’s Asthma Care
Measure Number of Patients Hospital Footnotes Hospital Score National Average Nat 90th Percentile State Average
No Data are available for this hospital.

Hospital Compare - Survey of Patient Hospital Experiences

Data are for the collection period beginning 07/01/2009 to 06/30/2010 posted on 04/20/2011 / Definitions
Report is based on information from Hospital Compare, a website created through the efforts of the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS) along with the Hospital Quality Alliance (HQA).  The HQA is a public-private collaboration established to promote reporting on hospital quality of care.

Click individual questions for detailed definitions and comparisons.
Survey question Measure Percent Measure Percent Measure Percent
Nurses communicated well Always 76% Usually 18% Sometimes 6%
Doctors communicated well Always 80% Usually 16% Sometimes 4%
Help received quickly Always 59% Usually 30% Sometimes 11%
Pain controlled well Always 69% Usually 24% Sometimes 7%
Staff explained medicines Always 60% Usually 18% Sometimes 22%
Room and bath kept clean Always 65% Usually 21% Sometimes 14%
Area quiet at night Always 54% Usually 32% Sometimes 14%
Given discharge instructions Yes 84% No 16%    
Overall hospital rating High 65% Medium 26% Low 9%
Would recommend hospital Definitely 66% Probably 28% No 6%

Hospital Compare - Outcome Measures

Data are for the collection period beginning 07/01/2006 to 06/30/2009 and posted on 04/20/2011

Report is based on information from Hospital Compare, a website created through the efforts of the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS) along with the Hospital Quality Alliance (HQA).  The HQA is a public-private collaboration established to promote reporting on hospital quality of care.

Click here for information about the Outcome Measures reported.

30-Day Risk Adjusted Mortality Rates
Measure Hospital Predicted Range National Average
Number Patients Mortality Rate from to
Heart Attack 554 12.7% 10.5% 15.1% 16.2%
Heart Failure 769 10.1% 8.4% 12.1% 11.2%
Pneumonia 753 9.8% 8.1% 11.9% 11.6%

30-Day Risk Adjusted Readmission Rates
Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Heart Attack 533 18.4% 16.0% 21.2% 19.9%
Heart Failure 890 23.0% 20.7% 25.6% 24.7%
Pneumonia 761 19.5% 17.1% 22.0% 18.3%

Hospital Compare - Efficiency Measures

Data are for the collection period beginning 01/01/2008 to 12/31/2008 and posted on 04/20/2011

Report is based on information from Hospital Compare, a website created through the efforts of the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS) along with the Hospital Quality Alliance (HQA).  The HQA is a public-private collaboration established to promote reporting on hospital quality of care.

Click here for information about the Outcome Measures reported.

Imaging Efficiency
Measure Number Patients Hospital Footnotes Hospital Score National Average State Average
OP-8. MRI Lumbar Spine for Low Back Pain  257    23.7%  32.7%  25.8%
OP-9. Mammography Follow-up Rates  3440    9.4%  8.4%  7.3%
OP-10. Abdomen CT - Use of Contrast Material  2515    0.688%  0.191%  0.258%
OP-11. Thorax CT - Use of Contrast Material  1602    0.113%  0.054%  0.037%

 

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