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.
Mishawaka
Heart Attack –Acute Myocardial Infarction (AMI)
| Key Indicators |
Mishawaka (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 |
100% |
95% |
100% |
19 out of 23 hospitals (3) |
| Percent of Heart Attack Patients Given Aspirin at Discharge |
100% |
94% |
100% |
14 out of 23 hospitals (3) |
| Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
100% |
92% |
100% |
19 out of 22 hospitals (4) |
| Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling |
100% |
96% |
100% |
21 out of 21 hospitals (5) |
| Percent of Heart Attack Patients Given Beta Blocker at Discharge |
100% |
94% |
100% |
12 out of 23 hospitals (3) |
| Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival |
No data |
45% |
100% |
No hospitals reporting this measure (6) |
| Percent of Heart Attack Patients Given PCI (Percutaneous Coronary Interventions) Within 90 Minutes of Arrival |
97% |
82% |
100% |
4 out of 16 hospitals (7) |
*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) South Bend data time period: October 2009 to March 2010.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on July 21, 2010. The latest reporting period is from October 2008 through September 2009 for all indicators.
(3) Only 23 hospitals at Trinity Health have cases for this indicator.
(4) Only 22 hospitals at Trinity Health have cases for this indicator.
(5) Only 21 hospitals at Trinity Health have cases for this indicator.
(6) No hospitals at Trinity Health have cases for this indicator.
(7) Only 16 hospitals at Trinity Health are doing PCI.
Heart Failure
| Key Indicators |
Mishawaka (1) |
National Average (2) |
Top 10% of Hospitals Nationwide (2) |
Trinity Health Hospitals at Top 10% |
| Percent of Heart Failure Patients Given Discharge Instructions |
96% |
79% |
100% |
2 out of 24 hospitals |
| Percent of Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function |
100% |
90% |
100% |
17 out of 24 hospitals |
| Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
96% |
90% |
100% |
12 out of 24 hospitals |
| Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling |
100% |
93% |
100% |
24 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) South Bend data time period: October 2009 to March 2010.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on July 21, 2010. The latest reporting period is from October 2008 through September 2009 for all indicators.
Pneumonia
| Key Indicators |
Mishawaka (1) |
National Average (2) |
Top 10% of Hospitals Nationwide (2) |
Trinity Health Hospitals at Top 10% |
| Percent of Pneumonia Patients Assessed and Given Pneumococcal Vaccination |
98% |
87% |
100% |
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 |
98% |
92% |
100% |
6 out of 24 hospitals |
| Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling |
100% |
91% |
100% |
16 out of 24 hospitals |
| Percent of Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival |
98% |
94% |
100% |
5 out of 24 hospitals |
| Percent of Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s) |
98% |
89% |
99% |
6 out of 24 hospitals |
| Percent of Pneumonia Patients Assessed and Given Influenza Vaccination (3) |
99% |
85% |
100% |
3 out of 24 hospital |
*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) South Bend data time period: October 2009 to March 2010.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on July 21, 2010. The latest reporting period is from October 2008 through September 2009 for most indicators.
Surgical Care Improvement/Surgical Infection Prevention
| Key Indicators |
Mishawaka (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 |
100% |
92% |
100% |
5 out of 25 hospitals |
| Percent of surgery patients who were given the right kind of antibiotic to help prevent infection |
98% |
95% |
100% |
3 out of 25 hospitals |
| Percent of surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) |
95% |
90% |
99% |
4 out of 25 hospitals |
| Percent of all heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery |
95% |
91% |
99% |
3 out of 12 hospitals (4) |
| 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% |
98% |
100% |
22 out of 25 hospitals |
| Percent of surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries |
96% |
88% |
100% |
6 out of 25 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 |
96% |
87% |
100% |
3 out of 25 hospitals |
| Percent of surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on the beta blockers during the period just before and after their surgery (3) |
95% |
87% |
100% |
2 out of 25 hospitals |
| Outpatients having surgery who got an antibiotic at the right time – within one hour before surgery (5) |
96% |
87% |
100% |
2 out of 25 hospitals |
| Outpatients having surgery who got the right kind of antibiotic (5) |
99% |
93% |
100% |
2 out of 25 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) South Bend data time period: October 2009 to March 2010.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on July 21, 2010. The latest reporting period is from October 2008 through September 2009 for most indicators.
(3) Percent of Surgery Patients Taking Heart Drugs Called Beta Blockers has a CMS reporting period between January 2009 and September 2009.
(4) Only 12 hospitals have cases for this indicator.
(5) Two new indicators for Outpatients Having Surgery with the CMS reporting period between July 2009 and September 2009.
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Plymouth
Heart Attack –Acute Myocardial Infarction (AMI)
| Key Indicators |
Plymouth (1) |
National Average (2) |
State Average (2) |
Trinity Health Hospitals at Top 10% |
| Percent of Heart Attack Patients Given Aspirin at Arrival |
100% |
95% |
100% |
19 out of 23 hospitals (3) |
| Percent of Heart Attack Patients Given Aspirin at Discharge |
92% |
94% |
100% |
14 out of 23 hospitals (3) |
| Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
100% |
92% |
100% |
19 out of 22 hospitals (4) |
| Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling |
100% |
96% |
100% |
21 out of 21 hospitals (5) |
| Percent of Heart Attack Patients Given Beta Blocker at Discharge |
92% |
94% |
100% |
12 out of 23 hospitals (3) |
| Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival |
nNo dataa |
45% |
100% |
No hospitals reporting this measure (6) |
| Percent of Heart Attack Patients Given PCI (Percutaneous Coronary Interventions) Within 90 Minutes of Arrival |
na |
82% |
100% |
4 out of 16 hospitals (7) |
*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) Plymouth data time period: October 2009 to March 2010.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on July 21, 2010. The latest reporting period is from October 2008 through September 2009 for all indicators.
(3) Only 23 hospitals at Trinity Health have cases for this indicator.
(4) Only 22 hospitals at Trinity Health have cases for this indicator.
(5) Only 21 hospitals at Trinity Health have cases for this indicator.
(6) No hospitals at Trinity Health have cases for this indicator.
(7) Only 16 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 |
94% |
79% |
100% |
2 out of 24 hospitals |
| Percent of Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function |
100% |
90% |
100% |
17 out of 24 hospitals |
| Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
93% |
90% |
100% |
12 out of 24 hospitals |
| Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling |
100% |
93% |
100% |
24 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) Plymouth data time period: October 2009 to March 2010.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on July 21, 2010. The latest reporting period is from October 2008 through September 2009 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 Assessed and Given Pneumococcal Vaccination |
100% |
87% |
100% |
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% |
92% |
100% |
6 out of 24 hospitals |
| Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling |
100% |
91% |
100% |
16 out of 24 hospitals |
| Percent of Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival |
100% |
94% |
100% |
5 out of 24 hospitals |
| Percent of Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s) |
92% |
89% |
99% |
6 out of 24 hospitals |
| Percent of Pneumonia Patients Assessed and Given Influenza Vaccination |
98% |
85% |
100% |
3 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) Plymouth data time period: October 2009 to March 2010.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on July 21, 2010. The latest reporting period is from October 2008 through September 2009 for most indicators.
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 |
100% |
92% |
100% |
5 out of 25 hospitals |
| Percent of surgery patients who were given the right kind of antibiotic to help prevent infection |
97% |
90% |
100% |
3 out of 25 hospitals |
| Percent of surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) |
97% |
90% |
99% |
4 out of 25 hospitals |
| Percent of all heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery |
na |
91% |
99% |
3 out of 12 hospitals (4) |
| 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% |
98% |
100% |
22 out of 25 hospitals |
| Percent of surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries |
100% |
88% |
100% |
6 out of 25 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 |
100% |
87% |
100% |
3 out of 25 hospitals |
| Percent of surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on the beta blockers during the period just before and after their surgery (3) |
91% |
87% |
100% |
2 out of 25 hospitals |
| Outpatients having surgery who got an antibiotic at the right time – within one hour before surgery (5) |
100% |
87% |
100% |
2 out of 25 hospitals |
| Outpatients having surgery who got the right kind of antibiotic (5) |
100% |
93% |
100% |
2 out of 25 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) Plymouth data time period: October 2009 to March 2010.
(2) National average and Top 10% of hospitals nationwide were obtained from the Hospital Compare website on July 21, 2010. The latest reporting period is from October 2008 through September 2009 for most indicators.
(3) Percent of Surgery Patients Taking Heart Drugs Called Beta Blockers has a CMS reporting period between January 2009 and September 2009.
(4) Only 12 hospitals have cases for this indicator.
(5) Two new indicators for Outpatients Having Surgery with the CMS reporting period between July 2009 and September 2009.
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