| Measure Name |
Description |
Reporting Period |
|---|
| Complications | This score combines information for common patient safety problems in the hospital. The score displayed is a ratio compared to the national average of 1.0 (PSI 90). (lower is better) | January 1, 2021 to December 31, 2021 |
| Accidental Puncture and Laceration |
This measure compares the observed number of accidental puncture and laceration per 1,000 patients with the statistically expected number of accidental puncture and laceration. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 15). |
January 1, 2021 to December 31, 2021 |
| Central Venous Catheter-related Bloodstream Infections |
This measure compares the observed number of central venous catheter-related bloodstream infections per 1,000 patients with the statistically expected number of central venous catheter-related bloodstream infections. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 07). |
January 1, 2021 to December 31, 2021 |
| Collapsed Lung caused by Medical Care |
This measure compares the observed number of collapsed lung caused by medical care per 1,000 patients with the statistically expected number of collapsed lung caused by medical care. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 06). |
January 1, 2021 to December 31, 2021 |
| Postoperative Hemorrhage or Hematoma |
This measure compares the observed number of postoperative hemorrhage or hematoma per 1,000 patients with the statistically expected number of postoperative hemorrhage or hematoma. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 09). |
January 1, 2021 to December 31, 2021 |
| Postoperative Hip Fracture |
This measure compares the observed number of postoperative hip fracture per 1,000 patients with the statistically expected number of postoperative hip fracture. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 08). |
January 1, 2021 to December 31, 2021 |
| Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) |
This measure compares the observed number of postoperative lung embolism or deep vein thrombosis (clotting) per 1,000 patients with the statistically expected number of postoperative lung embolism or deep vein thrombosis (clotting). The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 12). |
January 1, 2021 to December 31, 2021 |
| Postoperative Physiologic and Metabolic Derangement |
This measure compares the observed number of postoperative physiologic and metabolic derangement per 1,000 patients with the statistically expected number of postoperative physiologic and metabolic derangement. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 10). |
January 1, 2021 to December 31, 2021 |
| Postoperative Respiratory Failure |
This measure compares the observed number of postoperative respiratory failure per 1,000 patients with the statistically expected number of postoperative respiratory failure. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 11). |
January 1, 2021 to December 31, 2021 |
| Postoperative Sepsis |
This measure compares the observed number of postoperative sepsis per 1,000 patients with the statistically expected number of postoperative sepsis. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 13). |
January 1, 2021 to December 31, 2021 |
| Pressure Ulcer |
This measure compares the observed number of pressure ulcer per 1,000 patients with the statistically expected number of pressure ulcer. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 03). |
January 1, 2021 to December 31, 2021 |
| Wound Complications in Abdominal Wall Surgery |
This measure compares the observed number of wound complications in abdominal wall surgery per 1,000 patients with the statistically expected number of wound complications in abdominal wall surgery. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (PSI 14). |
January 1, 2021 to December 31, 2021 |
| Measure Name |
Description |
Reporting Period |
|---|
| Deaths - Other Conditions | This score combines hospital mortality information for common conditions. The score displayed is a ratio compared the the national average of 1.0 (IQI 91). (lower is better) | January 1, 2021 to December 31, 2021 |
| Acute Myocardial Infarction (AMI) Mortality Rate |
This measure compares the observed number of deaths per 1,000 patients with the statistically expected number of deaths. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (IQI 15) |
January 1, 2021 to December 31, 2021 |
| Carotid Endarterectomy Mortality Rate |
This measure compares the observed number of deaths per 1,000 patients with the statistically expected number of deaths. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (IQI 31) |
January 1, 2021 to December 31, 2021 |
| Gastrointestinal Hemorrhage Mortality Rate |
This measure compares the observed number of deaths per 1,000 patients with the statistically expected number of deaths. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (IQI 18) |
January 1, 2021 to December 31, 2021 |
| Heart Failure Mortality Rate |
This measure compares the observed number of deaths per 1,000 patients with the statistically expected number of deaths. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (IQI 16) |
January 1, 2021 to December 31, 2021 |
| Hip Fracture Mortality Rate |
This measure compares the observed number of deaths per 1,000 patients with the statistically expected number of deaths. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (IQI 19) |
January 1, 2021 to December 31, 2021 |
| Pneumonia Mortality Rate |
This measure compares the observed number of deaths per 1,000 patients with the statistically expected number of deaths. The score displayed is a ratio (observed over expected), which is compared to the national average of 1.0 (IQI 20) |
January 1, 2021 to December 31, 2021 |
| Measure Name |
Description |
Reporting Period |
|---|
| Hospital-Acquired Infections - Bloodstream | The CLABSI Overall Standardized Infection Ratio (SIR) summarizes the average performance across all available types of ICUs. The SIR compares the infection rates in a small population (a hospital) to infection rates in a standard population (NYS in the same year), after adjusting for risk factors that might affect the chance of developing an infection. The SIR is the actual number of infections in the hospital, divided by the number of infections that would be statistically predicted if the standard population (NYS) had the same risk distribution as the observed population. (lower is better) | January 1, 2019 to December 31, 2019 |
| CLABSIs, Cardiothoracic ICU |
A bloodstream infection associated with a central line, which is a tiny tube inserted into a large vein in the neck, chest, arm, or groin, can occur if germs enter around or within a central line device and then pass into the blood. All CLABSIs are measured as infections per 1000 central line days. No risk-adjusted rate is available for this measure. |
January 1, 2019 to December 31, 2019 |
| CLABSIs, Coronary ICU |
A bloodstream infection associated with a central line, which is a tiny tube inserted into a large vein in the neck, chest, arm, or groin, can occur if germs enter around or within a central line device and then pass into the blood. All CLABSIs are measured as infections per 1000 central line days. No risk-adjusted rate is available for this measure. |
January 1, 2019 to December 31, 2019 |
| CLABSIs, Medical ICU |
A bloodstream infection associated with a central line, which is a tiny tube inserted into a large vein in the neck, chest, arm, or groin, can occur if germs enter around or within a central line device and then pass into the blood. All CLABSIs are measured as infections per 1000 central line days. No risk-adjusted rate is available for this measure. |
January 1, 2019 to December 31, 2019 |
| CLABSIs, Medical-Surgical ICU |
A bloodstream infection associated with a central line, which is a tiny tube inserted into a large vein in the neck, chest, arm, or groin, can occur if germs enter around or within a central line device and then pass into the blood. All CLABSIs are measured as infections per 1000 central line days. |
January 1, 2019 to December 31, 2019 |
| CLABSIs, Neurosurgical ICU |
A bloodstream infection associated with a central line, which is a tiny tube inserted into a large vein in the neck, chest, arm, or groin, can occur if germs enter around or within a central line device and then pass into the blood. All CLABSIs are measured as infections per 1000 central line days. No risk-adjusted rate is available for this measure. |
January 1, 2019 to December 31, 2019 |
| CLABSIs, Newborns Level II/III Perinatal Centers |
A bloodstream infection associated with a central line, which is a tiny tube inserted into a large vein in the neck, chest, arm, or groin, can occur if germs enter around or within a central line device and then pass into the blood. Level II/III NICUs are patient care areas that provide care for newborns requiring Level III care as well as newborns that are not critically ill but may need extended observation or to gain weight. All CLABSIs are measured as infections per 1000 central line days. |
January 1, 2019 to December 31, 2019 |
| CLABSIs, Newborns Level III Perinatal Centers |
A bloodstream infection associated with a central line, which is a tiny tube inserted into a large vein in the neck, chest, arm, or groin, can occur if germs enter around or within a central line device and then pass into the blood. Level III NICUs are patient care areas that provide highly specialized care to newborns with serious illness, including premature birth and low birth weight and newborns under the supervision of a neonatologist. All CLABSIs are measured as infections per 1000 central line days. |
January 1, 2019 to December 31, 2019 |
| CLABSIs, Newborns Regional Perinatal Centers |
A bloodstream infection associated with a central line, which is a tiny tube inserted into a large vein in the neck, chest, arm, or groin, can occur if germs enter around or within a central line device and then pass into the blood. Regional Perinatal Centers (RPCs) are patient care areas that provide a highly specialized care to newborns with serious illness, including premature birth and low birth weight and newborns under the supervision of a neonatologist. RPCs serve as regional referral centers within the State for hospitals providing NICU care. All CLABSIs are measured as infections per 1000 central line days. |
January 1, 2019 to December 31, 2019 |
| CLABSIs, Pediatric ICU |
A bloodstream infection associated with a central line, which is a tiny tube inserted into a large vein in the neck, chest, arm, or groin, can occur if germs enter around or within a central line device and then pass into the blood. All CLABSIs are measured as infections per 1000 central line days. No risk-adjusted rate is available for this measure. |
January 1, 2019 to December 31, 2019 |
| CLABSIs, Surgical ICU |
A bloodstream infection associated with a central line, which is a tiny tube inserted into a large vein in the neck, chest, arm, or groin, can occur if germs enter around or within a central line device and then pass into the blood. All CLABSIs are measured as infections per 1000 central line days. No risk-adjusted rate is available for this measure. |
January 1, 2019 to December 31, 2019 |
| Measure Name |
Description |
Reporting Period |
|---|
| Hospital-Acquired Infections - Surgical Site | The overall SSI Standardized Infection Ratio (SIR) is calculated as the sum of the observed number of surgical site infections divided by the sum of the predicted number of surgical site infections. (lower is better) | January 1, 2017 to December 31, 2017 |
| CABG, Chest Site Infections |
Coronary artery bypass graft (CABG) is a surgical procedure for heart disease in which a vein or artery from another part of the body (donor site) is used to create an alternate path for blood to flow to the heart, bypassing a blocked artery. Surgical site infections of the chest incision are reported separately from donor site infections.
Surgical Site Infections (SSIs) are infections that occur after surgery at the incision site or deeper within the body where the surgery took place. Some SSIs are minor and only involve the skin or superficial tissues; others may be deeper and more serious.
All SSIs are measured as infections per 100 procedures. |
January 1, 2019 to December 31, 2019 |
| CABG, Donor Site Infections |
Coronary artery bypass graft (CABG) is a surgical procedure for heart disease in which a vein or artery from another part of the body (donor site) is used to create an alternate path for blood to flow to the heart, bypassing a blocked artery. Surgical site infections of the donor sites (such as the leg or arm) are reported separately from chest site infections.
Surgical Site Infections (SSIs) are infections that occur after surgery at the incision site or deeper within the body where the surgery took place. Some SSIs are minor and only involve the skin or superficial tissues; others may be deeper and more serious.
All SSIs are measured as infections per 100 procedures. |
January 1, 2019 to December 31, 2019 |
| Colon Surgery Infections |
Colon surgery is a procedure performed on the lower part of the digestive tract also known as the large intestine or colon.
Surgical Site Infections (SSIs) are infections that occur after surgery at the incision site or deeper within the body where the surgery took place. Some SSIs are minor and only involve the skin or superficial tissues, while others may be deeper and more serious.
All SSIs are measured as infections per 100 procedures. |
January 1, 2019 to December 31, 2019 |
| Hip Replacement Surgery Infections |
Hip replacement surgery involves removing the damaged hip sections and completely or partially replacing with an artificial hip joint.
Surgical Site Infections (SSIs) are infections that occur after surgery at the incision site or deeper within the body where the surgery took place. Some SSIs are minor and only involve the skin or superficial tissues; others may be deeper and more serious. All SSIs are measured as infections per 100 procedures. |
January 1, 2019 to December 31, 2019 |
| Hysterectomy Surgery Infections |
Surgical Site Infections (SSIs) are infections that occur after surgery at the incision site or deeper within the body where the surgery took place. Some SSIs are minor and only involve the skin or superficial tissues; others may be deeper and more serious. All SSIs are measured as infections per 100 procedures. |
January 1, 2019 to December 31, 2019 |
| Measure Name |
Description |
Reporting Period |
|---|
| Patient Satisfaction | Composite score of an entity's HCAHPS satisfaction ratings (higher is better) | April 1, 2022 to March 31, 2023 |
| Doctors Always Communicated Well |
This measure is used to assess the percentage of respondents who reported their doctors always communicated well. |
April 1, 2022 to March 31, 2023 |
| Nurses Always Communicated Well |
This measure is used to assess the percentage of respondents who reported their nurses always communicated well. |
April 1, 2022 to March 31, 2023 |
| Patient's Room Always Kept Quiet At Night |
This measure is used to assess the percentage of respondents who reported their room was always kept quiet at night. |
April 1, 2022 to March 31, 2023 |
| Patient's Room and Bathroom Always Kept Clean |
This measure is used to assess the percentage of respondents who reported their room and bathroom were always kept clean. |
April 1, 2022 to March 31, 2023 |
| Patients Always Received Help As Soon As They Wanted |
This measure is used to assess the percentage of respondents who reported that they always received help as soon as they wanted. |
April 1, 2022 to March 31, 2023 |
| Patients Given Information About Recovery At Home |
This measure is used to assess the percentage of respondents who reported whether ("Yes" or "No") they were provided specific discharge information. |
April 1, 2022 to March 31, 2023 |
| Patients who "Agree" they understood their care when they left the hospital |
This measure is used to assess the percentage of respondents who agreed that they understood their care when leaving the hospital |
April 1, 2022 to March 31, 2023 |
| Patients Would Definitely Recommend This Hospital to Friends and Family |
This measure is used to assess the percentage of respondents who reported whether ("Definitely No," "Probably No," "Probably Yes," or "Definitely Yes") they were willing to recommend this hospital to their family and friends. |
April 1, 2022 to March 31, 2023 |
| Percent of Patients Highly Satisfied |
This measure is used to assess adult inpatients' perception of their hospital. Patients rate their hospital on a scale from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible. |
April 1, 2022 to March 31, 2023 |
| Staff Always Explained About Medicines |
This measure is used to assess the percentage of respondents who reported that the staff always explained about medicines. |
April 1, 2022 to March 31, 2023 |
| Measure Name |
Description |
Reporting Period |
|---|
| Readmissions Within 30 Days | 30-day hospital-wide all- cause unplanned readmission (HWR) (lower is better) | July 1, 2021 to June 30, 2022 |
| Heart Attack Patients Readmitted to Hospital Within 30 Days |
This measure shows the all-cause 30-day readmission rate for patients discharged from a previous hospital stay for heart attack. |
July 1, 2019 to June 30, 2022 |
| Heart Failure Patients Readmitted to Hospital Within 30 Days |
This measure shows the all-cause 30-day readmission rate for patients discharged from a previous hospital stay for heart failure. |
July 1, 2019 to June 30, 2022 |
| Pneumonia Patients Readmitted to Hospital Within 30 Days |
This measure shows the all-cause 30-day readmission rate for patients discharged from a previous hospital stay for pneumonia. |
July 1, 2019 to June 30, 2022 |
