Hospital Compare Analysis - Greenville Memorial Hospital

National Statistics and COTH Statistics Data prepared for:
Hospital Compare Benchmark Report GREENVILLE MEMORIAL HOSPITAL

April 2011 release
Outcome Measures
Mortality Measures July 2005 - June 2008 July 2006 - June 2009
Heart Attack No Different than National Rate No Different than National Rate
Heart Failure No Different than National Rate No Different than National Rate
Pneumonia No Different than National Rate No Different than National Rate
Readmission Measures July 2005 - June 2008 July 2006 - June 2009
Heart Attack Better than National Rate Better than National Rate
Heart Failure Better than National Rate Better than National Rate
Pneumonia No Different than National Rate No Different than National Rate
Outcome Measure Notes
Hospital 30-Day all-cause death (mortality) and readmission rates. Result categories compared to National rates as assigned by CMS based on calculated
risk-adjusted rates.
Inpatient Clinical Measures

Heart Attack
1. Heart Attack Patients Given Aspirin at Arrival
Your Scores Over Time Summary Discharge Data for Jul 09 - Jun 10
99 100 99 100 100 75th 90th Your
Average Median Percentile Percentile Score Rating*
National 95.7 100.0 100.0 100.0 100.0

COTH Hospitals 99.0 99.0 100.0 100.0 100.0
Jul 08 - Oct 08 - Jan 09 - Apr 09 - Jul 09 - *AAMC-Assigned Ratings: Green = greater than or equal to the 75th percentile; Yellow = greater
Jun 09 Sep 09 Dec 09 Mar 10 Jun 10 than or equal to the median, less than the 75th percentile; Red = less than the median.
2. Heart Attack Patients Given Aspirin at Discharge

100 100 99 99 99 75th 90th Your
National 94.3 100.0 100.0 100.0 99.0

COTH Hospitals 98.8 99.0 100.0 100.0 99.0
3. Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
99 99 98 98 98 75th 90th Your
National 93.3 100.0 100.0 100.0 98.0

COTH Hospitals 96.4 98.0 100.0 100.0 98.0
Inpatient Clinical Measure Notes:

National rates differ from those reported on Hospital Compare website. Hospital Compare reports average case rates, while this report shows hospital-level rates.
[1] Data applies to those hospitals that submitted pediatric data to the Joint Commission as part of their core measures.
Source: AAMC Analysis of HHS Hospital Compare Database - April 2011 Page 1 of 12
April 2011 release
Inpatient Clinical Measures (Continued)

Heart Attack (Continued)
4. Heart Attack Patients Given Smoking Cessation Advice/Counseling
100 100 100 100 100 75th 90th Your
National 97.1 100.0 100.0 100.0 100.0

COTH Hospitals 99.7 100.0 100.0 100.0 100.0
5. Heart Attack Patients Given Beta Blocker at Discharge

100 100 100 100 100 75th 90th Your
National 94.4 100.0 100.0 100.0 100.0

COTH Hospitals 98.6 99.0 100.0 100.0 100.0
6. Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival

75th 90th Your
67 Average Median Percentile Percentile Score Rating*
50
National 45.6 50.0 100.0 100.0 50.0 **
0 COTH Hospitals 44.5 50.0 100.0 100.0 50.0 **

**The number of cases is too small for purposes of reliably predicting performance.
7. Heart Attack Patients Given PCI Within 90 Minutes Of Arrival

99 98 96 95 96 75th 90th Your
National 86.4 91.0 97.0 100.0 96.0

COTH Hospitals 86.9 90.0 96.0 100.0 96.0

April 2011 release

Heart Failure
1. Heart Failure Patients Given Discharge Instructions
93 93 91 90 93 75th 90th Your
National 82.0 90.0 96.0 100.0 93.0

COTH Hospitals 88.9 91.0 96.0 99.0 93.0
2. Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function
100 100 100 100 100 75th 90th Your
National 91.6 99.0 100.0 100.0 100.0

COTH Hospitals 98.8 100.0 100.0 100.0 100.0
3. Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
99 99 99 99 98 75th 90th Your
National 90.7 96.0 100.0 100.0 98.0

COTH Hospitals 95.6 97.0 99.0 100.0 98.0
4. Heart Failure Patients Given Smoking Cessation Advice/Counseling

100 100 100 100 100 75th 90th Your
National 93.7 100.0 100.0 100.0 100.0

COTH Hospitals 99.2 100.0 100.0 100.0 100.0

April 2011 release

Pneumonia
1. Pneumonia Patients Assessed and Given Pneumococcal Vaccination
94 94 95 96 95 75th 90th Your
National 89.0 95.0 98.0 100.0 95.0

COTH Hospitals 90.3 93.0 96.0 98.0 95.0
3. Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of
The First Hospital Dose Of Antibiotics
99 98 97 97 98 75th 90th Your
National 93.8 97.0 99.0 100.0 98.0

COTH Hospitals 93.4 95.0 97.0 99.0 98.0
4. Pneumonia Patients Given Smoking Cessation Advice/Counseling

100 100 100 100 100 75th 90th Your
National 92.3 100.0 100.0 100.0 100.0

COTH Hospitals 98.0 100.0 100.0 100.0 100.0
5. Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

98 98 98 98 99 75th 90th Your
National 94.1 96.0 99.0 100.0 99.0

COTH Hospitals 92.3 94.0 97.0 98.0 99.0

April 2011 release

Pneumonia (Continued)
6. Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s)
95 96 96 97 96 75th 90th Your
National 89.8 93.0 96.0 99.0 96.0

COTH Hospitals 91.6 93.0 96.0 98.0 96.0
7. Pneumonia Patients Assessed and Given Influenza Vaccination

91 91 90 93 93 75th 90th Your
National 87.5 93.0 98.0 100.0 93.0

COTH Hospitals 88.3 90.0 96.0 98.0 93.0
Surgical Infection Prevention

1. Surgery patients on Beta Blockers prior to Hospitalization and Who Received Beta Blockers Before and After Their
Surgery
88 91 93 93
86 75th 90th Your
National 89.4 94.0 98.0 100.0 93.0

COTH Hospitals 92.0 94.0 97.0 99.0 93.0
Jan 09 - Jan 09 - Jan 09 - Apr 09 - Jul 09 - *AAMC-Assigned Ratings: Green = greater than or equal to the 75th percentile; Yellow = greater
2. Surgical Patients Who Received Preventative Antibiotic(s) One Hour Before Incision
100 100 100 100 100 75th 90th Your
National 93.6 97.0 99.0 100.0 100.0

COTH Hospitals 96.8 98.0 99.0 99.0 100.0

April 2011 release

Surgical Infection Prevention (Continued)
3. Surgical Patients Who Received the Appropriate Antibiotic(s) for Their Surgery
99 99 99 99 99 75th 90th Your
National 95.1 98.0 99.0 100.0 99.0

COTH Hospitals 97.2 98.0 98.0 99.0 99.0
4. Surgical Patients Whose Preventative Antibiotic(s) Are Stopped within 24 Hours After Surgery
96 96 97 97 96 75th 90th Your
National 92.8 95.0 98.0 100.0 96.0

COTH Hospitals 94.2 95.0 97.0 98.0 96.0
5. Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose

98 98 98 98 99 75th 90th Your
National 91.8 94.0 97.0 99.0 99.0

COTH Hospitals 92.2 94.0 96.8 99.0 99.0
6. Surgery Patients with Appropriate Hair Removal

99 99 99 98 98 75th 90th Your
National 98.6 100.0 100.0 100.0 98.0

COTH Hospitals 99.3 100.0 100.0 100.0 98.0

April 2011 release

Surgical Infection Prevention (Continued)
7. Surgical Patients Whose Doctor Ordered Prophylaxis for Venous Thromboembolism (VTE)
99 99 99 99 99 75th 90th Your
National 90.2 95.0 98.0 100.0 99.0

COTH Hospitals 96.2 97.0 99.0 99.0 99.0
8. Surgical Patients Who Received Venous Thromboembolism (VTE) Prophylaxis

96 96 97 97 97 75th 90th Your
National 88.9 93.0 97.0 100.0 97.0

COTH Hospitals 94.5 96.0 98.0 99.0 97.0
9. Surgery Patients Whose Urinary Catheters Are Removed within 48 Hours After Surgery
Your Scores Over Time Summary Discharge Data for Jan 10 - Jun 10
85 84 75th 90th Your
National 86.8 92.0 97.0 100.0 84.0

COTH Hospitals 89.1 91.0 95.0 98.0 84.0
*AAMC-Assigned Ratings: Green = greater than or equal to the 75th percentile; Yellow = greater
Jan 10 - Mar 10 Jan 10 - Jun 10 than or equal to the median, less than the 75th percentile; Red = less than the median.
Children's Asthma Care

1. Children Who Received Reliever Medication While Hospitalized for Asthma [1]
75th 90th Your
N/A
National 99.9 100.0 100.0 100.0 N/A --
COTH Hospitals 100.0 100.0 100.0 100.0 N/A --

April 2011 release

Children's Asthma Care (Continued)
2. Children Who Received Systemic Corticosteroid Medication While Hospitalized for Asthma [1]
75th 90th Your
N/A
National 99.0 100.0 100.0 100.0 N/A --
3. Children and their Caregivers Who Received a Home Management Plan of Care Document While Hospitalized for
Asthma [1]
75th 90th Your
N/A
National 71.7 80.0 93.0 100.0 N/A --

April 2011 release
Outpatient Clinical Measures

Heart Attack or Chest Pain
1. Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival
75th 90th Your
N/A
National 47.7 50.0 75.0 100.0 N/A --
Jul 08 - Sep Jan 09 - Dec Apr 09 - Mar Jul 09 - Jun *AAMC-Assigned Ratings: Green = greater than or equal to the 75th percentile; Yellow = greater
09 09 10 10 than or equal to the median, less than the 75th percentile; Red = less than the median.
2. Asprin at Arrival
100 100 100 75th 90th Your
89
National 94.1 97.0 100.0 100.0 100.0 **

COTH Hospitals 91.9 100.0 100.0 100.0 100.0 **
3. Prophylactic Antibotic Initiated Within One Hour Prior to Surgical Incision

96 96 96 97 75th 90th Your
National 88.3 93.0 97.0 99.0 97.0

COTH Hospitals 90.5 93.0 96.0 98.0 97.0
Jul 09 - Sep Jul 09 - Dec Jul 09 - Mar Jul 09 - Jun *AAMC-Assigned Ratings: Green = greater than or equal to the 75th percentile; Yellow = greater
4. Prophylactic Antibiotic Selection for Surgical Patients

99 99 98 98 75th 90th Your
National 92.4 95.0 98.0 100.0 98.0

COTH Hospitals 92.7 95.0 97.0 98.0 98.0
Jul 09 - Sep Jul 09 - Dec Jul 09 - Mar Jul 09 - Jun *AAMC-Assigned Ratings: Green = greater than or equal to the 75th percentile; Yellow = greater
Outpatient Clinical Measure Notes:

[1] According to CMS, lower utilization is better.
[2] According to CMS, a number that is much lower than 8% may mean there's not enough follow-up. A number much higher than 14% may mean there's too
much unnecessary follow-up. The AAMC does not calculate a rating for this measure as good performance is based on a high and low-end range.
[3] The range for this measure is 0 to 1. According to CMS, a number very close to 1 may mean that too many patients are being given a double scan when a
single scan is all they need.
April 2011 release
Outpatient Clinical Measures (Continued)

Heart Attack or Heart Failure Timing
1. Median Time (minutes) to ECG [1]
75th 90th Your
National 134.6 9.0 6.0 3.0 8.0 **

8 8 8
2 COTH Hospitals 27.5 11.0 6.3 3.0 8.0 **
2. Median Time (minutes) to Transfer to Another Facility for Acute Coronary Intervention [1]
75th 90th Your
N/A
National 330.8 71.0 51.0 40.0 N/A --
N/A Jul 09 - Mar 10 Jul 09 - Jun 10 than or equal to the median, less than the 75th percentile; Red = less than the median.
Imaging Efficiency
1. MRI Lumbar Spine for Low Back Pain [1]
Your Scores Over Time Summary Discharge Data for Jan 08 - Dec 08
75th 90th Your
33.8 National 33.4 32.7 27.7 22.4 33.8

COTH Hospitals 30.0 29.6 25.3 20.0 33.8
Jan 08 - Dec 08 than or equal to the median, less than the 75th percentile; Red = less than the median.
2. Mammogram or Ultrasound Within 45 Days After Screening Mammogram [2]

75th 90th Your
National 8.8 8.0 5.6 3.9 9.2 --

COTH Hospitals 8.3 8.0 5.8 4.1 9.2 --
9.2

April 2011 release
Outpatient Clinical Measures (Continued)

Imaging Efficiency (Continued)
3. Outpatient CT scans of the abdomen that were "combination" (double) scans [3]
75th 90th Your
National 0.21 0.11 0.06 0.03 0.11

0.11 COTH Hospitals 0.17 0.12 0.07 0.04 0.11
4. Outpatient Thorax CT scans that were "combination" (double) scans [3]

75th 90th Your
National 0.09 0.02 0.01 0.00 0.03

COTH Hospitals 0.04 0.01 0.01 0.00 0.03
0.03

April 2011 release
Patient Satisfaction Measures

Percentages for Your Hospita National COTH
Jul 08 - Jul 09 - Percentiles Percentiles
Patient Satisfaction Jun 09 Jun 10 Trend 50th 75th 90th 50th 75th 90th
Would patients recommend the 72 73 70 76 82 72 77 82

hospital to friends and family? YES,
patients would definitely
recommend the hospital
How do patients rate the hospital 66 68 67 73 78 67 71 76
overall? Patients who gave a rating
of 9 or 10 (high)
How often did doctors communicate 77 77 80 84 87 77 79 82
well with patients? Doctors always
communicated well
How often did nurses communicate 74 76 76 79 83 74 77 79
well with patients? Nurses always
communicated well
How often did patients receive help 57 59 63 69 76 58 62 65
quickly from hospital staff? Patients
always received help as soon as
they wanted
How often did staff explain about 56 58 60 64 68 59 61 63
medicines before giving them to
patients? Staff always explained
How often was patients' pain well 68 68 69 72 76 67 70 72
controlled? Pain was always well
controlled
How often was the area around 65 66 58 64 71 51 57 62
patients' rooms kept quiet at night?
Always quiet at night
How often were the patients' rooms 65 68 70 76 82 65 69 72
and bathrooms kept clean? Room
was always clean
Were patients given information about 82 82 82 85 88 82 85 87
what to do during their recovery at
home? Yes, staff did give patients
this information
Number of completed surveys: 300 or More

Response Rate: 30%

Hospital Compare Analysis - Greenville Memorial Hospital

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National Statistics and COTH Statistics Data prepared for:

Hospital Compare Benchmark Report GREENVILLE MEMORIAL HOSPITAL

Inpatient Clinical Measures

National 95.7 100.0 100.0 100.0 100.0

2. Heart Attack Patients Given Aspirin at Discharge

National 94.3 100.0 100.0 100.0 99.0

National 93.3 100.0 100.0 100.0 98.0

Inpatient Clinical Measure Notes:

Inpatient Clinical Measures (Continued)

National 97.1 100.0 100.0 100.0 100.0

5. Heart Attack Patients Given Beta Blocker at Discharge

National 94.4 100.0 100.0 100.0 100.0

6. Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival

0 COTH Hospitals 44.5 50.0 100.0 100.0 50.0 **

7. Heart Attack Patients Given PCI Within 90 Minutes Of Arrival

National 86.4 91.0 97.0 100.0 96.0

Inpatient Clinical Measure Notes:

Inpatient Clinical Measures (Continued)

National 82.0 90.0 96.0 100.0 93.0

National 91.6 99.0 100.0 100.0 100.0

National 90.7 96.0 100.0 100.0 98.0

4. Heart Failure Patients Given Smoking Cessation Advice/Counseling

National 93.7 100.0 100.0 100.0 100.0

Inpatient Clinical Measure Notes:

Inpatient Clinical Measures (Continued)

National 89.0 95.0 98.0 100.0 95.0

National 93.8 97.0 99.0 100.0 98.0

4. Pneumonia Patients Given Smoking Cessation Advice/Counseling

National 92.3 100.0 100.0 100.0 100.0

5. Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

National 94.1 96.0 99.0 100.0 99.0

Inpatient Clinical Measure Notes:

Inpatient Clinical Measures (Continued)

National 89.8 93.0 96.0 99.0 96.0

7. Pneumonia Patients Assessed and Given Influenza Vaccination

National 87.5 93.0 98.0 100.0 93.0

Surgical Infection Prevention

National 89.4 94.0 98.0 100.0 93.0

National 93.6 97.0 99.0 100.0 100.0

Inpatient Clinical Measure Notes:

Inpatient Clinical Measures (Continued)

National 95.1 98.0 99.0 100.0 99.0

National 92.8 95.0 98.0 100.0 96.0

5. Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose

National 91.8 94.0 97.0 99.0 99.0

6. Surgery Patients with Appropriate Hair Removal

National 98.6 100.0 100.0 100.0 98.0

Inpatient Clinical Measure Notes:

Inpatient Clinical Measures (Continued)

National 90.2 95.0 98.0 100.0 99.0

8. Surgical Patients Who Received Venous Thromboembolism (VTE) Prophylaxis

National 88.9 93.0 97.0 100.0 97.0

National 86.8 92.0 97.0 100.0 84.0

Children's Asthma Care

Inpatient Clinical Measure Notes:

Inpatient Clinical Measures (Continued)

Inpatient Clinical Measure Notes:

Outpatient Clinical Measures

National 94.1 97.0 100.0 100.0 100.0 **

3. Prophylactic Antibotic Initiated Within One Hour Prior to Surgical Incision

National 88.3 93.0 97.0 99.0 97.0

4. Prophylactic Antibiotic Selection for Surgical Patients

National 92.4 95.0 98.0 100.0 98.0