Reporting Period: October 2011 - September 2012

	Compared to other Joint Commission Accredited Organizations
Measure Area	Nationwide	Statewide
SCIP - Infection Prevention Read More Close SCIP - Infection Prevention This category of evidence based measures assesses the overall use of indicated antibiotics for surgical infection prevention.

	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:
Patients having a surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* Read More Close Patients having a surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* This measure reports how often patients having surgery received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut. Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut. Note: Not every surgery requires antibiotics and this measure reports on those selected surgeries where evidence/experts have identified that antibiotics would be helpful. (See Quarterly Results)		100%	99%	100%	99%
	99% of 1108 eligible Patients7
Patients having surgery who received the appropriate medicine (antibiotic) which is shown to be effective for the type of surgery performed.* Read More Close Patients having surgery who received the appropriate medicine (antibiotic) which is shown to be effective for the type of surgery performed.* This measure reports how often patients who had surgery were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. Note: Not every surgery requires antibiotics and this measure reports on those selected surgeries where evidence/experts have identified that antibiotics would be helpful. (See Quarterly Results)		100%	99%	100%	99%
	99% of 1111 eligible Patients7
Patients who had surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* Read More Close Patients who had surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* This measure reports how often surgery patients whose medicine (an antibiotic) to prevent infection was stopped within 24 hours after the surgery ended. Giving medicine that prevents infection for more than 24 hours after the end of surgery is not helpful, unless there is a specific reason (for example, fever or other signs of infection). Note: Not every surgery requires antibiotics and this measure reports on those selected surgeries where evidence/experts have identified that antibiotics would be helpful. (See Quarterly Results)		100%	98%	100%	98%
	97% of 1086 eligible Patients7
Patients Having Blood Vessel Surgery* Read More Close Blood Vessel Surgery Overall report of hospital's performance on Surgical Infection Prevention Measure for Blood Vessel Surgery. (See Quarterly Results)		100%	97%	100%	97%
	97% of 210 eligible Patients7
Patients having blood vessel surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* Read More Close Patients having blood vessel surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* This measure reports how often patients having blood vessel surgery received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut. Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut. (See Quarterly Results)		100%	97%	100%	98%
	100% of 71 eligible Patients7
Patients having blood vessel surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* Read More Close Patients having blood vessel surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* This measure reports how often patients who had blood vessel surgery were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. (See Quarterly Results)		100%	99%	100%	99%
	96% of 71 eligible Patients7
Patients who had blood vessel surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* Read More Close Patients who had blood vessel surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* This measure reports how often blood vessel surgery patients whose medicine (an antibiotic) to prevent infection was stopped within 24 hours after the surgery ended. Giving medicine that prevents infection for more than 24 hours after the end of surgery is not helpful, unless there is a specific reason (for example, fever or other signs of infection). (See Quarterly Results)		100%	95%	100%	95%
	96% of 68 eligible Patients7
Patients Having Colon/Large Intestine Surgery* Read More Close Colon/Large Intestine Surgery Overall report of hospital's performance on Surgical Infection Prevention Measures for Colon/Large Intestine Surgery. (See Quarterly Results)		100%	95%	100%	95%
	97% of 299 eligible Patients7
Patients having colon/large intestine surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut. * Read More Close Patients having colon/large intestine surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut. * This measure reports how often patients having colon/large intestine surgery received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut. Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut. (See Quarterly Results)		100%	97%	100%	96%
	97% of 102 eligible Patients7
Patients having colon/large intestine surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* Read More Close Patients having colon/large intestine surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* This measure reports how often patients who had colon/large intestine surgery were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. (See Quarterly Results)		100%	94%	100%	94%
	96% of 102 eligible Patients7
Patients who had colon/large intestine surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* Read More Close Patients who had colon/large intestine surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* This measure reports how often colon/large intestine surgery patients whose medicine (an antibiotic) to prevent infection was stopped within 24 hours after the surgery ended. Giving medicine that prevents infection for more than 24 hours after the end of surgery is not helpful, unless there is a specific reason (for example, fever or other signs of infection). (See Quarterly Results)		100%	95%	100%	94%
	97% of 95 eligible Patients7
Patients Having Coronary Artery Bypass Graft Surgery* Read More Close Coronary Artery Bypass Graft Overall report of hospital's performance on Surgical Infection Prevention Measures for Coronary Artery Bypass Graft Surgery. (See Quarterly Results)		100%	99%	100%	99%
	99% of 332 eligible Patients7
Patients having coronary artery bypass graft surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* Read More Close Patients having coronary artery bypass graft surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* This measure reports how often patients having coronary artery bypass graft surgery received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut. Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut. (See Quarterly Results)		100%	99%	100%	99%
	100% of 111 eligible Patients7
Patients having coronary artery bypass graft surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* Read More Close Patients having coronary artery bypass graft surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* This measure reports how often patients who had coronary artery bypass graft surgery were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. (See Quarterly Results)		100%	100%	100%	100%
	100% of 111 eligible Patients7
Patients who had coronary artery bypass graft surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 48 hours after the surgery ended.* Read More Close Patients who had coronary artery bypass graft surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 48 hours after the surgery ended.* This measure reports how often coronary artery bypass graft surgery patients whose medicine (an antibiotic) to prevent infection was stopped within 48 hours after the surgery ended. Giving medicine that prevents infection for more than 48 hours after the end of surgery is not helpful, unless there is a specific reason (for example, fever or other signs of infection). (See Quarterly Results)		100%	98%	100%	98%
	99% of 110 eligible Patients7
Patients Having Hip Joint Replacement Surgery* Read More Close Hip Joint Replacement Overall report of hospital's performance on Surgical Infection Prevention Measures for Hip Joint Replacement Surgery. (See Quarterly Results)		100%	99%	100%	99%
	98% of 530 eligible Patients7
Patients having hip joint replacement surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* Read More Close Patients having hip joint replacement surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* This measure reports how often patients having hip joint replacement surgery received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut. Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut. (See Quarterly Results)		100%	99%	100%	99%
	99% of 178 eligible Patients7
Patients having hip joint replacement surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* Read More Close Patients having hip joint replacement surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* This measure reports how often patients who had hip joint replacement surgery were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. (See Quarterly Results)		100%	100%	100%	100%
	99% of 178 eligible Patients7
Patients who had hip joint replacement surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* Read More Close Patients who had hip joint replacement surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* This measure reports how often hip joint replacement surgery patients whose medicine (an antibiotic) to prevent infection was stopped within 24 hours after the surgery ended. Giving medicine that prevents infection for more than 24 hours after the end of surgery is not helpful, unless there is a specific reason (for example, fever or other signs of infection). (See Quarterly Results)		100%	98%	100%	98%
	97% of 174 eligible Patients7
Patients Having a Hysterectomy* Read More Close Hysterectomy Overall report of hospital's performance on Surgical Infection Prevention Measure for Hysterectomy Surgery. (See Quarterly Results)		100%	98%	100%	98%
	97% of 474 eligible Patients7
Patients having hysterectomy surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* Read More Close Patients having hysterectomy surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* This measure reports how often patients having hysterectomy surgery received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut. Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut. (See Quarterly Results)		100%	98%	100%	99%
	98% of 159 eligible Patients7
Patients having hysterectomy surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* Read More Close Patients having hysterectomy surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* This measure reports how often patients who had hysterectomy surgery were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. (See Quarterly Results)		100%	97%	100%	97%
	96% of 159 eligible Patients7
Patients who had hysterectomy surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* Read More Close Patients who had hysterectomy surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* This measure reports how often hysterectomy surgery patients whose medicine (an antibiotic) to prevent infection was stopped within 24 hours after the surgery ended. Giving medicine that prevents infection for more than 24 hours after the end of surgery is not helpful, unless there is a specific reason (for example, fever or other signs of infection). (See Quarterly Results)		100%	98%	100%	98%
	96% of 156 eligible Patients7
Patients Having Knee Joint Replacement Surgery* Read More Close Knee Replacement Overall report of hospital's performance on Surgical Infection Prevention Measures for Knee Joint Replacement Surgery. (See Quarterly Results)		100%	99%	100%	99%
	98% of 1031 eligible Patients7
Patients having knee joint replacement surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* Read More Close Patients having knee joint replacement surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* This measure reports how often patients having knee joint replacement surgery received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut. Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut. (See Quarterly Results)		100%	99%	100%	99%
	98% of 344 eligible Patients7
Patients having knee joint replacement surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* Read More Close Patients having knee joint replacement surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* This measure reports how often patients who had knee joint replacement surgery were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. (See Quarterly Results)		100%	100%	100%	100%
	99% of 344 eligible Patients7
Patients who had knee joint replacement surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* Read More Close Patients who had knee joint replacement surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* This measure reports how often knee joint replacement surgery patients whose medicine (an antibiotic) to prevent infection was stopped within 24 hours after the surgery ended. Giving medicine that prevents infection for more than 24 hours after the end of surgery is not helpful, unless there is a specific reason (for example, fever or other signs of infection). (See Quarterly Results)		100%	98%	100%	99%
	97% of 343 eligible Patients7
Patients Having Open Heart Surgery other than Coronary Artery Bypass Graft* Read More Close Open Heart Surgery Overall report of hospital's performance on Surgical Infection Prevention Measures for Open Heart Surgery. (See Quarterly Results)		100%	99%	100%	99%
	99% of 429 eligible Patients7
Patients having open heart surgery other than coronary artery bypass graft who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* Read More Close Patients having open heart surgery other than coronary artery bypass graft who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* This measure reports how often patients having open heart surgery other than coronary artery bypass graft received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut. Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut. (See Quarterly Results)		100%	99%	100%	99%
	100% of 143 eligible Patients7
Patients having open heart surgery other than coronary artery bypass graft who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* Read More Close Patients having open heart surgery other than coronary artery bypass graft who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* This measure reports how often patients who had open heart surgery other than coronary artery bypass graft were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. (See Quarterly Results)		100%	100%	100%	100%
	100% of 146 eligible Patients7
Patients who had open heart surgery other than coronary artery bypass graft and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 48 hours after the surgery ended.* Read More Close Patients who had open heart surgery other than coronary artery bypass graft and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 48 hours after the surgery ended.* This measure reports how often open heart surgery other than coronary artery bypass graft patients whose medicine (an antibiotic) to prevent infection was stopped within 48 hours after the surgery ended. Giving medicine that prevents infection for more than 48 hours after the end of surgery is not helpful, unless there is a specific reason (for example, fever or other signs of infection). (See Quarterly Results)		100%	98%	100%	98%
	98% of 140 eligible Patients7
Heart surgery patients with controlled blood sugar after surgery. Read More Close Heart surgery patients with controlled blood sugar after surgery. This measure reports the number of heart surgery patients that had a blood sugar of less than 200 on day one and day two after surgery. Infection is lowest in both diabetic and nondiabetic patients when blood sugar is controlled immediately after surgery. (See Quarterly Results)		100%	96%	100%	96%
	97% of 288 eligible Patients7
Surgery patients with proper hair removal. Read More Close Surgery patients with proper hair removal. This measure reports the number of surgical patients that have had hair at the site of the surgical cut removed properly. Infection is lowest when patients have hair removed with electrical clippers or hair removal cream. (See Quarterly Results)		100%	100%	100%	100%
	100% of 1485 eligible Patients7
Urinary Catheter Removed Read More Close Urinary Catheter Removed This measure reports the number of surgery patients whose urinary catheter was removed by the end of the second day after surgery. (See Quarterly Results)		100%	96%	100%	96%
	96% of 877 eligible Patients7
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 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. 10 - Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement. 11 - There were no eligible patients that met the denominator criteria.