National Benchmarks - IBM

National Benchmarks

Prepared for:Sample HospitalCity, STMedicare ID: 999999

Sample Hospital

Report Methodology NotesCOMPARISON GROUPSSo that we can compare your hospital with others most like it, we assign each hospital to one of five comparison groups according to operating bed size, teaching status, and residency/fellowship program involvement. Classification details are in the Study Overview.

Comparison Group Number of WinnersMajor Teaching Hospital 15Teaching Hospital 25Large Community Hospital 20Medium Community Hospital 20Small Community Hospital 20

BENCHMARK AND PEER GROUPSIn the Watson Health™ 100 Top study, we select 100 Benchmark hospitals (winners) based on overall performance in the most recent year of data available. Winners are selected by comparison group, as indicated in the table above.Peer group hospitals include all U.S. hospitals in our study database, excluding benchmark hospitals.In this custom report, we provide two types of comparisons for current performance and for multi-year trend performance:

• Profiled hospital versus comparison group Benchmark hospitals• Profiled hospital versus comparison group Peer hospitals

METHODOLOGY NOTESPresent on Admission (POA) coding was used in the risk models for mortality, complications and average length of stay. Due to the increasing number of diagnoses with the invalid POA code ‘0’, we made the following adjustments to the MEDPAR data:

1) Original, valid (Y,N,U,W or 1) POA codes assigned to diagnoses were retained

2) Where a POA code of ‘0’ appeared, we took the next four steps:a) We treated all principal diagnoses (dx) as ‘present on admission’b) We treated all secondary dx on the CMS exempt list as ‘exempt’c) We treated secondary dx for which the POA code ‘Y’ or ‘W’ appeared

more than 50 percent of the time in Watson Health’s all-payer database as ‘present on admission’

d) All others were treated as ‘not present’

RANK WEIGHTS AND PUBLIC DATA SOURCES

Measures Rank Wt Source

Risk-Adjusted Inpatient Mortality 12 MEDPAR FFY1 2016-20193

Risk-Adjusted Complications 12 MEDPAR FFY1 2016-20193

Healthcare-Associated Infections 1 CMS Hospital Compare CY2015-2019

30-Day Mortality (AMI, Heart Failure, Pneumonia, COPD, Stroke) 12

CMS Hospital Compare 3-yr data sets ending June 30 in 2015, 2016, 2017, 2018, 2019

30-Day Hospital-Wide Readmissions 12

CMS Hospital Compare 1-yr data sets ending June 30 in 2015, 2016, 2017, 2018, 2019

Severity-Adjusted Average Length of Stay 1 MEDPAR FFY1 2016-20193

Emergency Department Throughput 1 CMS Hospital Compare CY 2015,

2016, 2017, 2018, 2019Adjusted Inpatient Expense per Discharge 1 HCRIS 2020 Q4 2015-2019 cost

reports

Medicare Spend Per Beneficiary 1 CMS Hospital Compare CY2015-2019

Adjusted Operating Profit Margin 1 HCRIS 2020 Q4 2015-2019 cost reports

HCAHPS 1 CMS Hospital Compare CY2015-2019

1 Federal Fiscal year is Oct 1 through Sep 30.2 Small community hospitals' rank weights for these measures are increased to 1.25 to balance quality and operational domain weights, due to exclusion of the HAI measure from this comparison group.3 Measures with only 4 years of trend data points due to ICD-10 availability in MEDPAR data.

FOR MORE INFORMATIONFor a Study Overview, with full details on performance measures, methods used, and winner list, visit www.100tophospitals.com

Watson Health © IBM Corporation 2021 2 of 36

Sample Hospital

100 Top Hospitals Performance Matrix

INTEGRATED HOSPITAL PERFORMANCE COMPARISONThe 100 Top Hospitals® Performance Matrix, in a single view, compares your hospital’s current level of achievement and 5-year rate of improvement in percentiles. These percentiles are based on your hospital’s rank, overall and by measure, within your comparison group. This integrated performance comparison provides insight into the success of hospital performance improvement strategies relative to other similar hospitals.

INTERPRETING HOSPITAL PERFORMANCEOverall hospital performance is a composite score based on the sum of the ranks of individual measures. This sum is used to rank your hospital within your comparison group. The matrix “Overall” dot integrates your national rank percentile for current overall performance with your national rank percentile for multi-year overall rate of improvement. Rank percentiles for each individual measure are also graphed. Measures may fall into any one of four quadrants: Declining (lower left), Improving (upper left), Leading (upper right), or At Risk (lower right).100 Top Hospitals award winners are selected based on highest overall current performance. Winners fall into either the “Leading” or “At Risk” quadrants, depending on their multi-year rate of improvement performance. Those with a high rate of improvement will be “Leading” performers, and those who have fallen behind their comparison group median may be “At Risk” for falling behind peers in the future, if low rates of improvement continue.

Everest award winners fall into the right upper-most corner of the “Leading” performance quadrant. Everest winners are both a 100 Top Hospitals current performance winner and one of the 100 most improved hospitals on their multi-year trended performance in the same study year.

PERFORMANCE MATRIX NOTES

Missing Matrix Graph

The matrix graph will be missing if your hospital was excluded from the study or did not have enough years of data to be trended. If trend analysis could not be done, there also will be no trend graphs in this report. Exclusion notes are found at the end of the graphs section of this report.

Missing Measure Dots

A measure dot will be missing from the matrix if your hospital had too few useable data points (after outlier exclusions) to calculate a multi-year trend t-statistic, which is the ranked variable. In this case, the overall performance dot will also be missing. We cannot rank the hospital overall if one or more measures are missing. Notes on excluded data points are in the Appendix following the Performance Matrix graph.


Sample Hospital

100 Top Hospitals Performance Comparison Group

Profiled hospital compared to major teaching hospitals


Sample Hospital

2019 Performance and Five-Year Rate of Improvement Matrix

20

40

60

80

100

20 40 60 80 100100

12

1110

9

8

7

6 5

4

3

2

1

2019 Performance

2015

- 20

19 R

ate

of Im

prov

emen

t

DATA POINT KEY

1 OVERALL2 Inpatient Mortality

3 Complications

4 HAI

5 30-Day Mortality

6 30-Day H-W Readmit

7 ALOS

8 ED Measures

9 IP Expense/Disch

10 MSPB

11 Oper Profit Margin

12 HCAHPS

80 to 100 60 to 80 40 to 60 20 to 40 0 to 20

PROFILED HOSPITAL compared to:2019 major teaching hospitals: n = 2082015-2019 major teaching hospitals: n = 204


Sample Hospital

Performance and Improvement – Rank Percentiles Graphs

UNDERSTANDING THE GRAPHS

2019 Performance Rank Percentiles

This bar graph shows your hospital’s performance on each measure, in the most current year of data we analyzed, reported as rank percentiles. Individual measure percentiles are calculated by dividing your measure rank within your comparison group by the number of hospitals in the group and multiplying by 100.

The 2021 100 Top Hospitals benchmark hospitals (winners) were selected based only on 2019 performance.

2015-2019 Rate of Improvement Rank Percentiles

This bar graph shows your hospital’s rate of improvement on each measure, and overall, reported as rank percentiles. Individual measure percentiles are calculated by dividing your measure rank within your comparison group by the number of hospitals in the group and multiplying by 100. The overall rank percentile is based on the sum of your individual measure ranks, re-ranked by comparison group. The overall rank sum is then converted into a percentile. The overall rank percentile is not the average of the individual measure percentiles.

Measures with rank percentiles above the median are likely to move ahead of peers on performance in the future, if those rates of improvement have continued.

Hospitals with overall and measure-specific rank percentiles below the median are likely to fall behind peers on performance in the future, if those low rates of improvement have continued. And winners with a low overall rate of improvement are at risk for dropping out of the winner circle entirely.


Sample Hospital

2019 Performance Rank Percentiles

0.0

20.0

40.0

60.0

80.0

100.0

OVERALL InptMort

Comp HAI 30DMort

30DH-W

Readmit

ALOS EDMeas

IPExp

MSPB OperProf

HCAHPS

76.9

36.130.8

93.3

52.2

26.9

73.167.3

40.9

76.986.1 89.9

Perc

entil

e

50th

Profiled hospital compared to major teaching hospitals: n = 208

2015 - 2019 Rate of Improvement Rank Percentiles

0.0

20.0

40.0

60.0

80.0

100.0

OVERALL InptMort

Comp HAI 30DMort

30DH-W

Readmit

ALOS EDMeas

IPExp

MSPB OperProf

HCAHPS

55.3

90.2

45.1

70.1

40.7 42.6

96.1

28.4

71.0

34.3 37.1

9.3

Perc

entil

e

50th

Profiled hospital compared to major teaching hospitals: n = 204


Sample Hospital

100 Top Hospitals Current Profile Notes

CURRENT PROFILEThe 100 Top Hospitals® Current Profile analyzes your hospital’s performance in the most recent year available, using a national balanced scorecard of critical performance metrics:

• Risk-Adjusted Inpatient Mortality Index• Risk-Adjusted Complications Index• Mean Healthcare-Associated Infection Index• Mean 30-Day Mortality Rate (AMI, heart failure, pneumonia, COPD,

stroke)• 30-Day Hospital-Wide Readmission Rate• Severity-Adjusted Average Length of Stay• Mean Emergency Department Throughput• Inpatient Expense per Discharge (casemix- and wage-adjusted)• Medicare Spend Per Beneficiary*• Adjusted Operating Profit Margin• HCAHPS Top Box Percent (Overall Hospital Rating)

Using this Profile, you can identify your hospital’s level of performance achievement by individual measure and overall, and target higher performance. In addition, the Profile shows the level of achievement of national award-winning (benchmark) hospitals and the median performance of non-winning (peer) hospitals in your comparison group.

*Indicates a change in ranked measures for the 2021 study edition.

UNDERSTANDING THE GRAPHS

Profiled Hospital Compared with Benchmark and Peer

The hospital’s current performance is represented by individual bar graphs for each of the performance measures included in the 100 Top Hospitals national balanced scorecard. Each bar graph shows performance achievement levels for three groups: your hospital, the benchmark group median, and the peer group median.

Binomial Measures

The graphs for the binomial measures – in-hospital mortality and complications – also have a statistical significance note that indicates whether your hospital’s performance is better than expected, as expected, or worse than expected (99% confidence).For binomial measures, we rank your hospital on the z-score calculated from your observed and normalized expected values. Z-scores take statistical significance into account. If your graph note indicates your performance is “as expected,” your performance is average regardless of how high or low the index value.

Healthcare-Associated Infections, 30-Day Rates, Emergency Department Measures and HCAHPS Detail

This section contains bar graphs for the individual measures that make up the composite ranked measures: healthcare-associated infections, 30-day mortality, and emergency department throughput. Performance on each HCAHPS question is included for information. Only the Overall Hospital Rating question (an outcome metric) is ranked.


Sample Hospital

100 Top Hospitals Current Profile Notes

USE OF MEDIAN VALUESWhen 30-day individual measures are missing, we substitute class median values so your hospital can be ranked. This was done for the following measures:

• 30-day mortality rates (AMI, HF, pneumonia, COPD, stroke)

Note: If all individual measures are missing for the 30-day mortality measure, class medians are not used and the hospital is excluded from the study.

MISSING OR INCALCULABLE DATA POINTS

• No bar is displayed for your hospital if values were not reported or are incalculable.

• If a hospital was excluded from the study for missing or incalculable performance measures, the details are noted at the end of the graphs section.

• If a hospital was not eligible to be a winner due to statistically poor performance on inpatient mortality or complications (99% confidence), the details are noted at the end of the graphs section.

• If a hospital was not eligible to be a winner because it had one or more outliers (interquartile range methodology) for expense or profit, the details are noted at the end of the graphs section.

• If a hospital, assigned to the medium community hospital comparison group was not eligible to be a winner because it did not have at least two (2) of the three (3) individual healthcare-associated infection measures required for this comparison group, the details are noted at the end of the graphs section.

EXCLUDED MEASURES

Due to low patient counts for some measures, the below comparison groups exclude the listed measures from analysis.

Small Community Hospitals• Healthcare-associated infections for all measures (HAI-1 – HAI-6)• 30-day mortality rate for AMI patients

Medium Community Hospitals• Surgical site infection from colon surgery (HAI-3)• Surgical site infection from abdominal hysterectomy (HAI-4)• Methicillin-resistant Staphylococcus aureus blood laboratory-

identified events (HAI-5)Large Community Hospitals

• Surgical site infection from abdominal hysterectomy (HAI-4)Teaching Hospitals

• Surgical site infection from abdominal hysterectomy (HAI-4)

Note: See Study Overview for a full list of included HAI measures.

MEASURES FOR INFORMATION ONLY

These measures, whose graphs with peer and benchmark group comparisons are presented in a separate section at the end of the report, are not included in your hospital’s overall performance rating and are not used to select the 100 Top award-winning hospitals.

MORE INFORMATION ON METHODOLOGIES

The methodology section of the 100 Top Hospitals Study Overview provides more details on the calculation of each performance measure and an indication of whether higher or lower values are favorable. It also describes the methodologies for calculating confidence limits and outliers, and for determining statistically poor performance on the mortality and complications measures.

See Study Overview for more details. Visit www.100tophospitals.com


Sample Hospital

100 Top Hospitals Trend Profile NotesTREND PROFILE OVERVIEWThe 100 Top Hospitals® Trend Profile analyzes your hospital’s rate of improvement over five years, using a balanced scorecard of critical performance metrics:

• Risk-Adjusted Inpatient Mortality Index• Risk-Adjusted Complications Index• Mean Healthcare-Associated Infection Index• Mean 30-Day Mortality Rate (AMI, heart failure, pneumonia, COPD,

stroke)• 30-Day Hospital-Wide Readmission Rate• Severity-Adjusted Average Length of Stay • Mean Emergency Department Throughput• Inpatient Expense per Discharge (casemix- and wage-adjusted)• Medicare Spend Per Beneficiary• Adjusted Operating Profit Margin• HCAHPS Top Box Percent (Overall Hospital Rating)

Minimum Data Requirements for RankingWe require a minimum of four (4) valid data points for each measure (including the most current year) to include a hospital in the Trend Profile ranking.

UNDERSTANDING THE GRAPHSImprovement Trends Versus Comparison Group Quintiles (Color Quintile Graphs)Your hospital’s rate of improvement for each of the individual performance measures is represented by graphs showing your hospital’s actual data points for each year as a set of black dots connected by line segments. These data points are displayed against a background of quintile ranges for the data points of all hospitals in your comparison group. Each range is color-coded to indicate rate of improvement level, from dark green (best

quintile) to red (worst quintile). You can use these graphs to see whether your organization’s trajectory over time is mostly flat, moving ahead of or falling behind other similar hospitals.A statistical significance note is displayed for each graph, indicating whether your performance is improving, not changing, or worsening over the five years we analyzed (99% confidence for mortality and complications; 95%, all other measures). We rank each measure using the t-statistic of the regression line through the data points (slope/S.E.).

Use of Median Values and Composite MeasuresFor each data year, when individual 30-day mortality measures are missing, the median value of your comparison group is substituted in order to calculate and display the composite mean 30-day value. However, if ALL individual 30-day mortality measures are missing for that data year, then median values are not used to calculate the composite mean and the data point will not be displayed on the color quintile graphs.To determine whether your hospital had a valid data point for the mean healthcare-associated infection index measure, we applied the same minimum eligibility requirements and individual HAI measure exclusions by comparison group as the current profile, to each historical year of data. Note: The CDC’s National Healthcare Safety Network updated its baseline HAI risk adjustment data to a standard based upon data from 2015, with new SIR values reported starting in January 2017.

Missing Data PointsIndividual data points are missing on the color quintile graphs when values are not reported, or if your comparison group’s median value has been substituted in a specific year.

Data Point Time PeriodsData points on the graphs – labeled 2015, 2016, 2017, 2018, 2019 – represent various data periods. See Report Methodology Notes page, Rank Weights and Public Data Sources table for more details.


Sample Hospital

Risk-adjusted inpatient mortality index2019 IP MORTALITY PERFORMANCE

0.00

0.20

0.40

0.60

0.80

1.00

1.20

ProfiledHospital

BenchmarkMedian

PeerMedian

1.04

0.911.00

IND

EX

Profiled hospital is statistically AS expected (99% confidence)

▼ DesiredDirection

Benchmark hospitals are the winners in the comparison group: n = 15

Peer hospitals are the non-winners in the comparison group: n = 193

Note: 2019 values on the current and trend graphs will not match due to different norm factors used to normalize the expected values.

2016-2019 IP MORTALITY RATE OF IMPROVEMENT

0.40

0.60

0.80

1.00

1.20

1.40

1.60

2016 2017 2018 2019

IND

EX

Profiled hospital is NOT CHANGING (99% confidence)

> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40

Min to 20 Profiled Hospital

Hospital performance compared to peer hospitals quintiles: n = 204

HOSPITALCOMPARISON GROUP

PROFILED HOSPITAL

PERCENTILE POINTS ► 20th 40th 60th 80th Value Upper C.I. Lower C.I.

YEARS

2016 0.90 1.00 1.10 1.20 1.32 1.43 1.21

2017 0.89 0.99 1.08 1.19 1.26 1.36 1.16

2018 0.87 0.96 1.06 1.18 1.12 1.21 1.03

2019 0.84 0.93 1.02 1.13 1.01 1.10 0.94


Sample Hospital

Risk-adjusted complications index2019 COMPLICATIONS PERFORMANCE

0.00

0.20

0.40

0.60

0.80

1.00

1.20

ProfiledHospital

BenchmarkMedian

PeerMedian

1.07

0.94 0.97

IND

EX

Profiled hospital is statistically AS expected (99% confidence)





2016-2019 COMPLICATIONS RATE OF IMPROVEMENT

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

2016 2017 2018 2019

IND

EX


> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40




PROFILED HOSPITAL

PERCENTILE POINTS ► 20th 40th 60th 80th Value Upper C.I. Lower C.I.

YEARS

2016 0.79 0.92 1.03 1.19 0.95 1.04 0.86

2017 0.82 0.95 1.05 1.19 0.89 0.98 0.81

2018 0.84 0.95 1.06 1.20 0.90 0.99 0.82

2019 0.82 0.91 1.01 1.19 1.06 1.16 0.97


Sample Hospital

Mean HAI standardized infection ratio2019 HAI PERFORMANCE

0.00

0.20

0.40

0.60

0.80

1.00

ProfiledHospital

BenchmarkMedian

PeerMedian

0.67 0.64

0.82

IND

EX




2015-2019 HAI RATE OF IMPROVEMENT

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

2015 2016 2017 2018 2019

IND

EX


> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40




PROFILEDHOSPITAL

PERCENTILE POINTS ► 20th 40th 60th 80th Value

YEARS

2015 0.74 0.85 1.00 1.17 0.83

2016 0.78 0.93 1.07 1.22 0.79

2017 0.76 0.86 1.01 1.22 0.57

2018 0.72 0.82 0.94 1.11 0.68

2019 0.64 0.75 0.87 1.06 0.67


Sample Hospital

Mean 30-day mortality rate2019 30D MORTALITY PERFORMANCE

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

ProfiledHospital

BenchmarkMedian

PeerMedian

11.9% 11.5% 12.0%

PER

CEN

T




2015-2019 30D MORTALITY RATE OF IMPROVEMENT

8.0

9.0

10.0

11.0

12.0

13.0

14.0

15.0

16.0

2015 2016 2017 2018 2019

PER

CEN

T


> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40




PROFILEDHOSPITAL


YEARS

2015 11.5 12.2 12.9 13.6 12.8

2016 11.3 12.0 12.6 13.3 11.8

2017 10.9 11.9 12.5 13.1 11.1

2018 11.0 11.6 12.3 12.9 11.0

2019 10.8 11.5 12.3 12.8 11.9


Sample Hospital

30-day hospital-wide readmission rate2019 30D HOSP-WIDE READMIT PERFORMANCE

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

ProfiledHospital

BenchmarkMedian

PeerMedian

16.7%15.1%

16.2%

PER

CEN

T

No different than CMS national rate (95% confidence)




2015-2019 30D HOSP-WIDE READMIT RATE OF IMPROVEMENT

13.0

14.0

15.0

16.0

17.0

18.0

19.0

20.0

2015 2016 2017 2018 2019

PER

CEN

T


> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40




PROFILEDHOSPITAL


YEARS

2015 15.4 16.1 16.6 17.1 16.5

2016 15.3 15.7 16.2 16.8 16.8

2017 15.2 15.7 16.1 16.7 16.6

2018 15.1 15.5 16.0 16.5 16.2

2019 15.3 15.8 16.3 16.9 16.7


Sample Hospital

Severity-adjusted average length of stay2019 ALOS PERFORMANCE

0.0

1.0

2.0

3.0

4.0

5.0

6.0

ProfiledHospital

BenchmarkMedian

PeerMedian

4.63 4.425.00

DA

YS





2016-2019 ALOS RATE OF IMPROVEMENT

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

2016 2017 2018 2019

DA

YS

Profiled hospital is IMPROVING (95% confidence)

> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40




PROFILEDHOSPITAL


YEARS

2016 4.52 4.78 5.03 5.40 4.77

2017 4.51 4.77 5.02 5.35 4.75

2018 4.53 4.80 5.05 5.37 4.68

2019 4.58 4.87 5.11 5.47 4.67


Sample Hospital

Mean emergency department throughput2019 ED PERFORMANCE

0

40

80

120

160

200

240

ProfiledHospital

BenchmarkMedian

PeerMedian

173161

205

MIN

UTE

S




2015-2019 ED RATE OF IMPROVEMENT

100

150

200

250

300

350

400

450

2015 2016 2017 2018 2019

MIN

UTE

S


> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40




PROFILEDHOSPITAL


YEARS

2015 152 173 205 234 167

2016 148 177 205 241 168

2017 148 181 208 242 175

2018 154 185 211 251 175

2019 150 182 209 256 173


Sample Hospital

Adjusted inpatient expense per discharge2019 INPT EXPENSE PERFORMANCE

0

2,000

4,000

6,000

8,000

10,000

ProfiledHospital

BenchmarkMedian

PeerMedian

$8,765

$6,420

$8,456

DO

LLA

RS




2015-2019 INPT EXPENSE RATE OF IMPROVEMENT

3,0004,000

5,0006,0007,0008,000

9,00010,00011,000

12,00013,00014,000

2015 2016 2017 2018 2019

DO

LLA

RS


> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40




PROFILEDHOSPITAL


YEARS

2015 6,348 7,219 7,929 9,016 9,013

2016 6,749 7,467 8,165 9,273 8,730

2017 6,777 7,582 8,234 9,298 9,110

2018 6,631 7,443 8,433 9,480 9,343

2019 6,817 7,682 8,724 9,741 8,765


Sample Hospital

Medicare spend per beneficiary index2019 MSPB PERFORMANCE

0.00

0.20

0.40

0.60

0.80

1.00

1.20

ProfiledHospital

BenchmarkMedian

PeerMedian

0.98 0.97 1.01

IND

EX




2015-2019 MSPB RATE OF IMPROVEMENT

0.80

0.85

0.90

0.95

1.00

1.05

1.10

1.15

2015 2016 2017 2018 2019

IND

EX


> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40




PROFILEDHOSPITAL


YEARS

2015 0.97 0.99 1.01 1.03 0.96

2016 0.97 1.00 1.01 1.03 0.97

2017 0.98 1.00 1.01 1.04 0.99

2018 0.98 1.00 1.02 1.04 0.98

2019 0.97 1.00 1.02 1.04 0.98


Sample Hospital

Adjusted operating profit margin2019 PROFIT PERFORMANCE

0

2

4

6

8

10

12

ProfiledHospital

BenchmarkMedian

PeerMedian

11.3% 11.7%

3.8%PER

CEN

T

▲ DesiredDirection



2015-2019 PROFIT RATE OF IMPROVEMENT

-40

-30

-20

-10

0

10

20

30

40

2015 2016 2017 2018 2019

PER

CEN

T


> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40




PROFILEDHOSPITAL


YEARS

2015 0.2 3.6 6.7 11.2 12.3

2016 -0.8 2.7 5.6 10.5 13.4

2017 -1.3 2.2 5.4 11.3 9.4

2018 -2.7 1.8 5.1 10.1 11.0

2019 -2.1 2.9 6.3 10.0 11.3


Sample Hospital

HCAHPS: overall rating question2019 HCAHPS TOP BOX PERFORMANCE

0

20

40

60

80

100

ProfiledHospital

BenchmarkMedian

PeerMedian

80.0% 77.0%71.0%

PER

CEN

T

▲ DesiredDirection

QUESTION KEY:Overall rating:How do patients rate the hospital overall?



2015-2019 HCAHPS TOP BOX RATE OF IMPROVEMENT

50

60

70

80

90

100

2015 2016 2017 2018 2019

PER

CEN

T


> 80 to Max

> 60 to 80

> 40 to 60

> 20 to 40




PROFILEDHOSPITAL


YEARS

2015 64.0 69.0 73.0 77.0 83.0

2016 65.0 70.0 73.0 77.0 83.0

2017 65.0 70.0 74.0 78.0 83.0

2018 65.0 70.0 74.0 77.0 78.0

2019 65.0 70.0 74.0 77.0 80.0


Sample Hospital

2019 Hospital performance – detail graphs

This section of your report contains the detail graphs of those measures that are ranked based on a composite of individual measures. These include:

• Healthcare-associated infections

• 30-day mortality (AMI, HF, pneumonia, COPD and stroke)

• Emergency department throughput (median min to inpt room; median min to ED d/c)

• HCAHPS – Note: We do not rank on the composite of the individual measures; the ranked measure is for the overall rating question. The individual detailed survey questions are displayed for information only.


Sample Hospital

Healthcare-associated infections SIR measure detail2019 HAI PERFORMANCE

0.00

0.20

0.40

0.60

0.80

1.00

1.20

CLABSI CAUTI SSI:COLON SSI:HYSTER MRSA C.DIFF

0.61

0.460.56

0.85

1.10

0.460.510.58

0.73

0.97

0.630.57

0.68 0.71

0.93 0.98

0.83

0.61

IND

EX (S

IR)

HEALTHCARE-ASSOCIATED INFECTIONS ABBREVIATION KEYCLABSI Central line-associated blood stream

infections

CAUTI Catheter-associated urinary tract infections

SSI:COLON Surgical site infection from colon surgery

SSI:HYSTER Surgical site infection from abdominal hysterectomy

MRSA Methicillin-resistant staphylococcus aureus blood laboratory-identified events

C.DIFF Clostridium difficile laboratory-identified events

Profiled Hospital

Benchmark Median

Peer Median

▼ Desired Direction

Benchmark hospitals are the winners in the comparison group: n = 15 Peer hospitals are the non-winners in the comparison group: n = 193


Sample Hospital

30-day mortality rates by patient condition2019 PERFORMANCE FOR 30D MORTALITY

0.0 2.0 4.0 6.0 8.0

10.0 12.0 14.0 16.0 18.0

AMI HF PNEU COPD STROKE

12.5

10.0

12.4

7.7

16.8

12.2 10.2

14.9

7.6

13.7 12.4

10.0

14.5

7.9

14.3

PER

CEN

T

Profiled Hospital

Benchmark Median

Peer Median




Sample Hospital

Emergency department throughput measure detail2019 ED PERFORMANCE

0

50

100

150

200

250

Med Min Inp Room Med Min Disch

136

209

130

186185

213

MIN

UTE

S

EMERGENCY DEPARTMENT ABBREVIATION KEY

Med MinInp Room

Median time patients spent in the ED, after decision to admit as inpt and before leaving ED for their room

Med MinDisch

Median time patients spent in the ED before being sent home

Profiled Hospital

Benchmark Median

Peer Median




Sample Hospital

HCAHPS questions – only overall rating used in ranking2019 HCAHPS PERFORMANCE

0

20

40

60

80

100

Overallrating

Drs commwell

Nursescomm well

Quickhelp

Medsexplained

Room areaquiet

Room/bathclean

Info forhome

UnderstoodCare

Wouldrecommend

80 83 81

65 64 65 66

88

57

83 77

81 81

66 62 60

71

88

55

79 71

79 78

61 62 54

67

87

52

73

TOP

BO

X PE

RC

ENT

QUESTION KEY

Overall rating How do patients rate the hospital overall?Drs comm well How often did doctors communicate well with patients?Nurses comm well How often did nurses communicate well with patients?Quick help How often did patients receive help quickly from hospital staff?Meds explained How often did staff explain about medicines before giving them to patients?Room area quiet How often was the area around patients rooms kept quiet at night?Room/bath clean How often were the patients rooms and bathrooms kept clean?Info for home Were patients given information about what to do during their recovery at home?Understood care How often did patients understand their care at discharge?Would recommend Would patients recommend the hospital to friends and family?

Profiled Hospital

Benchmark Median

Peer Median

▲ Desired Direction



Sample Hospital

HCAHPS questions, con’t2019 HCAHPS PERFORMANCE

0

20

40

60

80

100

Bathroomhelp

Call buttonhelp

Medunderstand

Preferacknowledged

Managehealth

Help afterdischarge

Drs explainedwell

Drs listenedwell

Drs treatedwell

66 64 64

51 55

86 78

82 89

69 62 62

49 54

85

75 79

87

63 60 59

45 51

85

74 77 86

TOP

BO

X PE

RC

ENT

QUESTION KEY

Bathroom help How often did patients receive bathroom help as soon as they wanted?Call button help How often did patients receive help after using the call button as soon as they wanted?Med understanding How often did patients understand the purpose of their medications when leaving the hospital?Prefer acknowledged How often did the staff take patients' preferences into account when determining health care needs?Manage health How often did patients understand their responsibilities in managing their health?Help after discharge How often did patients discuss whether they would need help after discharge?Drs explained well How often did doctors explain things in a way patients could understand?Drs listened well How often did doctors listen carefully to patients?Drs treated well How often did doctors treat patients with courtesy and respect?

Profiled Hospital

Benchmark Median

Peer Median




Sample Hospital

HCAHPS questions, con’t2019 HCAHPS PERFORMANCE

0

20

40

60

80

100

New medexplained

Nursesexplained well

Nurseslistened well

Nursestreated well

Side effectsdiscussed

Written info onsymptoms

79 77 79 87

49

90

78 76 78

88

48

90

76 75 75

85

48

88

TOP

BO

X PE

RC

ENT

QUESTION KEY

New med explained How often did staff communicate what the new medication was for?Nurses explained well How often did nurses explain things in a way patients could understand?Nurses listened well How often did nurses listen carefully to patients?Nurses treated well How often did nurses treat patients with courtesy and respect?Side effects discussed How often did staff discuss possible side effects when receiving a new medication?Written info on symptoms Did patients receive written information about possible symptoms to look out for after discharge?

Profiled Hospital

Benchmark Median

Peer Median




Sample Hospital

Supplemental information-only measuresThis section of your report contains measures that we are profiling only for informational purposes; they were not included in ranking or determination of winners. We welcome your comments and feedback on the usefulness and relevance of these measures in assessing leadership’s ability to drive high-level, balanced performance.

• 30-day readmission rate by patient condition- AMI, HF, pneumonia, THA/TKA, COPD

• 30-day / 90-day Medicare episode of payment measures by patient condition- 30-day payment for AMI / HF / PN patients- 90-day payment for THA/TKA patients

• 30-day excess days in acute care (EDAC) measures- AMI, HF, pneumonia patients

• 90-day complication measure- THA/TKA patients

• Patient safety indicator (PSI) measures- PSI-3 Pressure sores - PSI-11 Postoperative Respiratory Failure Rate- PSI-6 Collapsed lung due to medical treatment - PSI-12 Serious blood clots after surgery- PSI-8 Broken hip from a fall after surgery - PSI-13 Blood stream infection after surgery- PSI-9 Perioperative Hemorrhage or Hematoma Rate - PSI-14 A wound that splits open after surgery on the abdomen or pelvis- PSI-10 Postoperative Acute Kidney Injury Requiring Dialysis Rate - PSI-15 Accidental cuts and tears from medical treatment

- PSI-90 Serious complications

• Unplanned hospital visits after hospital outpatient surgery (OP-36) measure


Sample Hospital

30-day readmission rates by patient condition2019 PERFORMANCE FOR 30D READMISSIONS

0.0

4.0

8.0

12.0

16.0

20.0

24.0

28.0

AMI HF PNEU THA/TKA COPD

16.0

23.5

18.1

4.7

19.2

15.5

20.8

16.7

3.9

18.9 16.2

22.3

17.2

4.0

19.6

PER

CEN

T

Profiled Hospital

Benchmark Median

Peer Median




Sample Hospital

30-day episode of payment measures by patient condition2019 30D PAYMENT PERFORMANCE FOR AMI 2019 30D PAYMENT PERFORMANCE FOR PNEUMONIA

0

4,000

8,000

12,000

16,000

20,000

24,000

28,000

ProfiledHospital

BenchmarkMedian

PeerMedian

$24,255 $25,214 $25,741

DO

LLA

RS


0

4,000

8,000

12,000

16,000

20,000

ProfiledHospital

BenchmarkMedian

PeerMedian

$18,233 $18,322 $18,790

DO

LLA

RS


2019 30D PAYMENT PERFORMANCE FOR HF

02,0004,0006,0008,000

10,00012,00014,00016,00018,00020,000

ProfiledHospital

BenchmarkMedian

PeerMedian

$16,569$17,784 $17,878

DO

LLA

RS




Sample Hospital

30-day excess days in acute care measures by patient condition2019 30D EDAC PERFORMANCE FOR AMI 2019 30D EDAC PERFORMANCE FOR PNEUMONIA

-8.0

-4.0

0.0

4.0

8.0

12.0

16.0

ProfiledHospital

BenchmarkMedian

PeerMedian

7.30

-4.30

14.60

DA

YS


0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

ProfiledHospital

BenchmarkMedian

PeerMedian

37.60

7.40

26.80

DA

YS


2019 30D EDAC PERFORMANCE FOR HF

-5.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

ProfiledHospital

BenchmarkMedian

PeerMedian

30.30

-2.50

21.80

DA

YS




Sample Hospital

90-day episode payment and complication rate for THA/TKA2019 90D PAYMENT PERFORMANCE FOR THA/TKA 2019 90D COMPLICATIONS PERFORMANCE FOR THA/TKA

0

4,000

8,000

12,000

16,000

20,000

24,000

28,000

ProfiledHospital

BenchmarkMedian

PeerMedian

$24,176

$18,820$20,914

DO

LLA

RS


0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

ProfiledHospital

BenchmarkMedian

PeerMedian

3.2%

2.3% 2.4%

PER

CEN

T




Sample Hospital

Patient safety indicator measures2019 PSI PERFORMANCE

0.00

2.00

4.00

6.00

8.00

10.00

PSI-3 PSI-6 PSI-8 PSI-9 PSI-10 PSI-11 PSI-12 PSI-13 PSI-14 PSI-15

3.70

0.18 0.10

2.23 2.15

8.12

5.465.85

1.00 1.21

0.49 0.23 0.10

2.58

1.05

4.72

3.17

4.18

0.911.21

0.640.26 0.11

2.57

1.34

5.73

4.424.95

0.891.29

RA

TE*

*Rate per 1000 discharges

PSI KEY

PSI-3 Pressure soresPSI-6 Collapsed lung due to medical treatmentPSI-8 Broken hip from a fall after surgeryPSI-9 Perioperative Hemorrhage or Hematoma RatePSI-10 Postoperative Acute Kidney Injury Requiring Dialysis RatePSI-11 Postoperative Respiratory Failure RatePSI-12 Serious blood clots after surgeryPSI-13 Blood stream infection after surgeryPSI-14 A wound that splits open after surgery on the abdomen or pelvisPSI-15 Accidental cuts and tears from medical treatment

Profiled Hospital

Benchmark Median

Peer Median




Sample Hospital

Patient safety indicator 90: Serious complicationsOP-36: Unplanned hospital visits after hospital outpatient surgery2019 PSI 90 PERFORMANCE 2019 UNPLANNED VISITS PERFORMANCE

0.00

0.40

0.80

1.20

1.60

2.00

2.40

ProfiledHospital

BenchmarkMedian

PeerMedian

2.05

0.83

1.12

IND

EX


0.000.100.200.300.400.500.600.700.800.901.00

ProfiledHospital

BenchmarkMedian

PeerMedian

0.901.00

0.90

IND

EX




Legal Disclaimer© IBM Corporation 2021. All Rights Reserved.

The information contained in this publication is provided for informational purposes only. While efforts were made to verify the completeness and accuracy of the information contained in this publication, it is provided AS IS without warranty of any kind, express or implied. In addition, this information is based on IBM’s current product plans and strategy, which are subject to change by IBM without notice. IBM shall not be responsible for any damages arising out of the use of, or otherwise related to, this publication or any other materials. Nothing contained in this publication is intended to, nor shall have the effect of, creating any warranties or representations from IBM or its suppliers or licensors, or altering the terms and conditions of the applicable license agreement governing the use of IBM software.

References in this presentation to IBM products, programs, or services do not imply that they will be available in all countries in which IBM operates. Product release dates and/or capabilities referenced in this presentation may change at any time at IBM’s sole discretion based on market opportunities or other factors, and are not intended to be a commitment to future product or feature availability in any way. Nothing contained in these materials is intended to, nor shall have the effect of, stating or implying that any activities undertaken by you will result in any specific sales, revenue growth or other results.

Performance is based on measurements and projections using standard IBM benchmarks in a controlled environment. The actual throughput or performance that any user will experience will vary depending upon many factors, including considerations such as the amount of multiprogramming in the user's job stream, the I/O configuration, the storage configuration, and the workload processed. Therefore, no assurance can be given that an individual user will achieve results similar to those stated here.

All customer examples described are presented as illustrations of how those customers have used IBM products and the results they may have achieved. Actual environmental costs and performance characteristics may vary by customer.

IBM, the IBM logo, ibm.com, Watson, and Watson Health are trademarks of International Business Machines Corp., registered in many jurisdictions worldwide. Other product and service names might be trademarks of IBM or other companies. A current list of IBM trademarks is available on the Web at “Copyright and trademark information” at ibm.com/legal/copytrade.

Documents

National Benchmarks - IBM