Quality Report Cards
Quality Reporting
As an active and involved partner in your care, Trinity Health provides quality and safety data of our member hospitals in the U.S. so you have the information to make the best decisions for you and your family.
The clinical data found on our quality report cards are combined scores of
25 Trinity Health hospitals in seven states over a six-month period. These scores are updated on a quarterly basis. The measurements are consistent with the ones on the Centers for Medicare & Medicaid Services (CMS) and the Hospital Quality Alliance (HQA) at www.hospitalcompare.hhs.gov.
Categories
Heart attack
A heart attack (acute myocardial infarction or AMI) occurs when blood stops flowing to a part of the heart muscle. The lack of blood flow is often caused by a clot in one of the heart's blood vessels. Without the oxygen carried in the blood, part of the heart muscle dies or is damaged.
Heart failure
Heart failure, also called congestive heart failure, is a life-threatening condition in which the heart can no longer pump enough blood to the rest of the body.
Pneumonia
Pneumonia is an inflammation of the lungs caused by an infection. Many different organisms can cause it, including bacteria, viruses and fungi.
Pneumonia is a common illness that affects millions of people each year in the United States.
Surgical infection prevention
The risk of wound infection can significantly be reduced by making sure patients get the right medications at the right time on the day of their surgery.
South Bend
Heart Attack –Acute Myocardial Infarction (AMI)
| Key Indicators |
South Bend (1) |
National Average (2) |
Top 10% of Hospitals Nationwide (2) |
Trinity Health Hospitals at Top 10% |
| Percent of Heart Attack Patients Given Aspirin at Arrival |
97% |
94% |
100% |
15 out of 24 hospitals |
| Percent of Heart Attack Patients Given Aspirin at Discharge |
100% |
93% |
100% |
11 out of 24 hospitals |
| Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
83% |
90% |
100% |
16 out of 24 hospitals |
| Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling |
100% |
95% |
100% |
21 out of 22 hospitals (3) |
| Percent of Heart Attack Patients Given Beta Blocker at Discharge |
97% |
93% |
100% |
14 out of 24 hospitals |
| Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival |
na |
41% |
100% |
1 out of 1 hospital (4) |
| Percent of Heart Attack Patients Given PCI (Percutaneous Coronary Interventions) Within 90 Minutes of Arrival |
95% |
77% |
97% |
3 out of 15 hospitals (5) |
*The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your doctor if you have questions about your treatment.
(1) Trinity Health data time period: January 2009 to June 2009.
(2)National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on September 29, 2009. The latest reporting period is from January 2008 through December 2008 for all indicators.
(3) Only 22 hospitals at Trinity Health have cases for this indicator.
(4) Only 1 hospital at Trinity Health has cases for this indicator.
(5) Only 15 hospitals at Trinity Health are doing PCI.
Heart Failure
| Key Indicators |
South Bend (1) |
National Average (2) |
Top 10% of Hospitals Nationwide (2) |
Trinity Health Hospitals at Top 10% |
| Percent of Heart Failure Patients Given Discharge Instructions |
94% |
76% |
99% |
3 out of 24 hospitals |
| Percent of Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function |
100% |
89% |
100% |
15 out of 24 hospitals |
| Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
97% |
89% |
100% |
7 out of 24 hospitals |
| Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling |
100% |
91% |
100% |
21 out of 24 hospitals |
*The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your doctor if you have questions about your treatment.
(1) Trinity Health data time period: January 2009 to June 2009.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on September 29, 2009. The latest reporting period is from January 2008 through December 2008 for all indicators.
Pneumonia
| Key Indicators |
South Bend (1) |
National Average (2) |
Top 10% of Hospitals Nationwide (2) |
Trinity Health Hospitals at Top 10% |
| Percent of Pneumonia Patients Given Oxygenation Assessment |
100% |
99% |
100% |
22 out of 22 hospitals (3) |
| Percent of Pneumonia Patients Assessed and Given Pneumococcal Vaccination |
99% |
84% |
99% |
4 out of 24 hospitals |
| Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics |
100% |
91% |
100% |
8 out of 24 hospitals |
| Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling |
100% |
89% |
100% |
20 out of 24 hospitals |
| Percent of Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival |
96% |
93% |
100% |
4 out of 24 hospitals |
| Percent of Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s) |
99% |
87% |
97% |
15 out of 24 hospitals |
| Percent of Pneumonia Patients Assessed and Given Influenza Vaccination (4) |
94% |
82% |
100% |
4 out of 24 hospitals |
*The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your doctor if you have questions about your treatment.
(1) Trinity Health data time period: January 2009 to June 2009.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on September 29, 2009. The latest reporting period is from January 2008 through December 2008 for most indicators.
(3) Only 22 hospitals at Trinity Health have cases for this indicator.
(4) For "Given Influenza Vaccination" indicator, hospital compare website reports the data from October 2008 through December 2008; Trinity Health are reporting the data from October 2008 through March 2009.
Surgical Care Improvement/Surgical Infection Prevention
| Key Indicators |
South Bend (1) |
National Average (2) |
Top 10% of Hospitals Nationwide (2) |
Trinity Health Hospitals at Top 10% |
| Percent of surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection |
98% |
89% |
99% |
6 out of 24 hospitals |
| Percent of surgery patients who were given the right kind of antibiotic to help prevent infection |
99% |
94% |
100% |
7 out of 24 hospitals |
| Percent of surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) |
94% |
87% |
98% |
8 out of 24 hospitals |
| Percent of all heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery |
93% |
85% |
100% |
1 out of 12 hospitals (3) |
| Percent of surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream not a razor) |
100% |
96% |
100% |
21 out of 24 hospitals |
| Percent of surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries |
92% |
87% |
99% |
4 out of 24 hospitals |
| Percent of patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery |
89% |
84% |
98% |
6 out of 24 hospitals |
*The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your doctor if you have questions about your treatment.
(1) Trinity Health data time period: January 2009 to June 2009.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on September 29, 2009. The latest reporting period is from January 2008 through December 2008 for all indicators.
(3) Only 12 hospitals have cases for this indicator.
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Plymouth
Heart Attack –Acute Myocardial Infarction (AMI)
| Key Indicators |
SJRMC-Plymouth (1) |
National Average (2) |
State Average (2) |
Trinity Health Hospitals at Top 10% |
| Percent of Heart Attack Patients Given Aspirin at Arrival |
100% |
94% |
100% |
15 out of 24 hospitals |
| Percent of Heart Attack Patients Given Aspirin at Discharge |
100% |
93% |
100% |
11 out of 24 hospitals |
| Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
100% |
90% |
100% |
16 out of 24 hospitals |
| Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling |
100% |
95% |
100% |
21 out of 22 hospitals (3) |
| Percent of Heart Attack Patients Given Beta Blocker at Discharge |
100% |
93% |
100% |
14 out of 24 hospitals |
| Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival |
na |
41% |
100% |
1 out of 1 hospital (4) |
| Percent of Heart Attack Patients Given PCI (Percutaneous Coronary Interventions) Within 90 Minutes of Arrival |
na |
77% |
97% |
3 out of 15 hospitals (5) |
*The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your doctor if you have questions about your treatment.
(1) Trinity Health data time period: January 2009 to June 2009.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on September 29, 2009. The latest reporting period is from January 2008 through December 2008 for all indicators.
(3) Only 22 hospitals at Trinity Health have cases for this indicator.
(4) Only 1 hospital at Trinity Health has cases for this indicator.
(5) Only 15 hospitals at Trinity Health are doing PCI.
Heart Failure
| Key Indicators |
Plymouth (1) |
National Average (2) |
Top 10% of Hospitals Nationwide (2) |
Trinity Health Hospitals at Top 10% |
| Percent of Heart Failure Patients Given Discharge Instructions |
78% |
76% |
99% |
3 out of 24 hospitals |
| Percent of Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function |
98% |
89% |
100% |
15 out of 24 hospitals |
| Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
92% |
89% |
100% |
7 out of 24 hospitals |
| Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling |
100% |
91% |
100% |
21 out of 24 hospitals |
*The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your doctor if you have questions about your treatment.
(1) Trinity Health data time period: January 2009 to June 2009.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on September 29, 2009. The latest reporting period is from January 2008 through December 2008 for all indicators.
Pneumonia
| Key Indicators |
Plymouth (1) |
National Average (2) |
Top 10% of Hospitals Nationwide (2) |
Trinity Health Hospitals at Top 10% |
| Percent of Pneumonia Patients Given Oxygenation Assessment |
100% |
99% |
100% |
22 out of 22 hospitals (3) |
| Percent of Pneumonia Patients Assessed and Given Pneumococcal Vaccination |
98% |
84% |
99% |
4 out of 24 hospitals |
| Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics |
100% |
91% |
100% |
8 out of 24 hospitals |
| Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling |
100% |
89% |
100% |
20 out of 24 hospitals |
| Percent of Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival |
98% |
93% |
100% |
4 out of 24 hospitals |
| Percent of Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s) |
100% |
87% |
97% |
15 out of 24 hospitals |
| Percent of Pneumonia Patients Assessed and Given Influenza Vaccination (4) |
99% |
82% |
100% |
4 out of 24 hospitals |
*The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your doctor if you have questions about your treatment.
(1) Trinity Health data time period: January 2009 to June 2009.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on September 29, 2009. The latest reporting period is from January 2008 through December 2008 for most indicators.
(3) Only 22 hospitals at Trinity Health have cases for this indicator.
(4) For "Given Influenza Vaccination" indicator, hospital compare website reports the data from October 2008 through December 2008; Trinity Health are reporting the data from October 2008 through March 2009.
Surgical Care Improvement/Surgical Infection Prevention
| Key Indicators |
Plymouth (1) |
National Average (2) |
Top 10% of Hospitals Nationwide (2) |
Trinity Health Hospitals at Top 10% |
| Percent of surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection/td>
| 97% |
89% |
99% |
6 out of 24 hospitals |
| Percent of surgery patients who were given the right kind of antibiotic to help prevent infection/td>
| 97% |
94% |
100% |
7 out of 24 hospitals |
| Percent of surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) |
92% |
87% |
98% |
8 out of 24 hospitals |
| Percent of all heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery |
na |
85% |
100% |
1 out of 12 hospitals (3) |
| Percent of surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream not a razor) |
100% |
96% |
100% |
21 out of 24 hospitals |
| Percent of surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries |
96% |
87% |
99% |
4 out of 24 hospitals |
| Percent of patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery |
63% |
84% |
98% |
6 out of 24 hospitals |
*The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your doctor if you have questions about your treatment.
(1) Trinity Health data time period: January 2009 to June 2009.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on September 29, 2009. The latest reporting period is from January 2008 through December 2008 for all indicators.
(3) Only 12 hospitals have cases for this indicator.
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