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.
Saint Francis Hospital
701 North Clayton Street
Wilmington, DE 19805
(302) 421-4100

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  116    97%  99%  100%  99%
AMI-2. Aspirin at Discharge  109    99%  98%  100%  99%
AMI-3. ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)  33    94%  96%  100%  95%
AMI-4. Smoking Cessation Advice/Counseling  49    100%  99%  100%  100%
AMI-5. Beta Blocker at Discharge  102    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  11  1  73%  90%  100%  90%

Condition: Heart Failure
Measure Number Patients Hospital Footnotes Hospital Score National Average Nat 90th Percentile State Average
HF-1. Discharge Instructions  205    94%  88%  100%  92%
HF-2. Evaluation of Left Ventricular Systolic (LVS) Function  234    96%  98%  100%  99%
HF-3. ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)  102    97%  94%  100%  94%
HF-4. Smoking Cessation Advice/Counseling  54    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  N/A  5  N/A  54%  100%  0%
OP-3b. Median Time to transfer patients for Acute Coronary Intervention  N/A  5  N/A  61 minutes  40 minutes  72 minutes
OP-4. Aspirin at Arrival  N/A  5  N/A  95%  100%  100%
OP-5. Median Time to ECG  N/A  5  N/A  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  310     95%  92%  99%  90%
OP-7. Prophylactic Antiobiotic Selection  304     94%  94%  100%  87%

Condition: Pneumonia
Measure Number Patients Hospital Footnotes Hospital Score National Average Nat 90th Percentile State Average
PN-2. Pneumococcal Vaccination Status  68    90%  93%  100%  91%
PN-3b. Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospita  122    93%  96%  100%  94%
PN-4. Smoking Cessation Advice/Counseling  48    100%  97%  100%  100%
PN-5c. Initial Antibiotic(s) within 6 Hours After Arrival  112    96%  95%  100%  94%
PN-6. Appropriate Initial Antibiotic Selection  85    92%  92%  99%  90%
PN-7. Influenza Vaccination Status  52    92%  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  136    94%  93%  100%  95%
SCIP-INF-1. Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision  333    93%  97%  100%  97%
SCIP-INF-2. Prophylactic Antibiotic Selection  336    98%  97%  100%  99%
SCIP-INF-3. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time  301    94%  94%  100%  97%
SCIP-INF-4. Blood glucose controlled in days following heart surgery  82    85%  93%  99%  94%
SCIP-INF-6. Safe method of hair removal from surgical site used when needed  551    100%  99%  100%  100%
SCIP-INF-9. Urinary catheter removed within two days following surgery  48    90%  90%  100%  95%
SCIP-VTE-1. Recommended Venous Thromboembolism Prophylaxis Ordered  125    96%  94%  100%  96%
SCIP-VTE-2. Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery  125    94%  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 71% Usually 20% Sometimes 9%
Doctors communicated well Always 78% Usually 16% Sometimes 6%
Help received quickly Always 59% Usually 23% Sometimes 18%
Pain controlled well Always 63% Usually 23% Sometimes 14%
Staff explained medicines Always 54% Usually 16% Sometimes 30%
Room and bath kept clean Always 59% Usually 23% Sometimes 18%
Area quiet at night Always 57% Usually 28% Sometimes 15%
Given discharge instructions Yes 74% No 26%    
Overall hospital rating High 60% Medium 25% Low 15%
Would recommend hospital Definitely 60% Probably 29% No 11%

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 190 14.9% 11.9% 18.5% 16.2%
Heart Failure 363 11.0% 8.8% 13.7% 11.2%
Pneumonia 230 12.5% 9.7% 15.9% 11.6%

30-Day Risk Adjusted Readmission Rates
Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Heart Attack 176 19.5% 16.3% 23.1% 19.9%
Heart Failure 458 25.8% 22.5% 29.3% 24.7%
Pneumonia 229 19.9% 16.6% 23.6% 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  37  1  21.6%  32.7%  25.8%
OP-9. Mammography Follow-up Rates  864    3.5%  8.4%  7.3%
OP-10. Abdomen CT - Use of Contrast Material  410    0.022%  0.191%  0.258%
OP-11. Thorax CT - Use of Contrast Material  295    0.003%  0.054%  0.037%

 

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