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	Symbol Key
	This organization achieved the best possible results
	This organization’s performance is above the target range/value.
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	This organization’s performance is below the target range/value.
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Quality Report
Hospital

Culpeper Memorial Hospital, Inc.
Org ID: 6334

National Quality Improvement Goals: Pregnancy Care

Reporting Period: January 2009 - December 2009

	Compared to other Joint Commission Accredited Organizations
Measure Area	Nationwide	Statewide
Pregnancy Care Read More Close Pregnancy Care This category of evidence based measures assesses the overall quality of care provided to Pregnant patients.	²	²

Compared to other Joint Commission Accredited Organizations

Nationwide Statewide

Measure Hospital
Results Top 10% Scored at Least: Average Rate: Top 10% Scored at Least: Average Rate:

Inpatient neonatal mortality
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Inpatient neonatal mortality

This measure reports how often infants died before 28 days of birth. This measure is adjusted to reflect the fact that some babies are sicker than others at or shortly after birth.

(See Quarterly Results)

0.00% Actual Rate
0.06% Expected Rate
of 440 eligible Patients

Third or fourth degree laceration
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Third or fourth degree laceration

Vaginal tears during delivery. This measure reports how often patients have significant tears between the vagina and anus while having a baby. These types of tears can lead to other medical complications.

(See Quarterly Results)

2.48% 3.03% 2.82% 3.13%

5.08% Actual Rate
4.44% Expected Rate
of 354 eligible Patients

The Joint Commission only reports measures endorsed by the National Quality Forum.

* This information is part of the Hospital Quality Alliance. This information can also be viewed at www.hospitalcompare.hhs.gov.

---- Null value or data not displayed.

1 - The measure or measure set was not reported.

2 - The measure set does not have an overall result.

3 - The number of patients is not enough for comparison purposes.

4 - The measure meets the Privacy Disclosure Threshold rule.

5 - The organization scored above 90% but was below most other organizations.

6 - The measure results are not statistically valid.

7 - The measure results are based on a sample of patients.

8 - The number of months with measure data is below the reporting requirement.

9 - The measure results are temporarily suppressed pending resubmission of updated data.

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