West Suburban Medical Center

Patient Safety - All

Healthcare-Associated Infections

Hospitals in Illinois are participating in programs to reduce the number of infections acquired during hospital stays. While it is difficult to reduce infections to zero, following specific protocols can greatly reduce the risk.

The Hospital Report Card Act (Illinois Public Act 93-563) requires Illinois hospitals to report central line associated bloodstream infections (CLABSIs) as well as surgical site infections (SSIs). As of January 1, 2012, hospitals are also mandated to report Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections and Clostridioides difficileinfections. Infections are reported through the CDC’s National Healthcare Safety Network (NHSN) surveillance system. The Standardized Infection Ratio (SIR) , a summary measure used to determine whether infection data are statistically different from the national average, is presented for each type of infection shown below. Read more about healthcare-associated infections in Illinois . To learn more about the data collection methods using the CDC's National Health Safety Network (NHSN) surveillance system, read the Report Card methodology .

Clostridioides difficile infections (CDI) and Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections

Facility-wide Healthcare Facility Onset Incidence Rates for CDI and MRSA are presented below. These rates are based on results of laboratory tests that were obtained on or after day four of an inpatient stay and do not consider presence or timing of clinical signs or symptoms. The Standardized Infection Ratio (SIR) is presented, which is a summary measure used to determine if rates of CDI and MRSA bloodstream infections are statistically different from the national average. Statewide summaries of CDI and MRSA data arranged by hospital are also included. Note: Starting with 2016 data, new methods for risk adjustment were used.

Statistical Significance

Statistically significantly better than the national average or performing at the best possible rate

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
45	Complete Reporting: Zero infections. Number of predicted LabID events too low to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
48	No Target Procedures Performed
49	Complete Reporting: 20 or Fewer Procedures Performed
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
155	Complete Reporting: 20 or Fewer Procedures Performed
169	Exempt: No Licensed ICU Beds

Central Line Associated Bloodstream Infections (CLABSIs)

Presented below are annual central line-associated bloodstream infections (CLABSIs) occurring in critical care units, also known as intensive care units (ICUs). ICU-specific summary data for CLABSI are provided using the Standardized Infection Ratio(SIR) . Statewide summaries of CLABSI data arranged by ICU type and hospital are also included.

Statistical Significance

Statistically significantly better than the national average or performing at the best possible rate

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
45	Complete Reporting: Zero infections. Number of predicted LabID events too low to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
48	No Target Procedures Performed
49	Complete Reporting: 20 or Fewer Procedures Performed
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
155	Complete Reporting: 20 or Fewer Procedures Performed
169	Exempt: No Licensed ICU Beds

Adult CLABSI

Pediatric CLABSI

Ped. CLABSI Measure	Result	SIR
Pediatric Medical-Surgical ICU Q1 2019 - Q4 2019 Result N/A infections, N/A central-line days ¹⁶⁹ Rating SIR: N/A ¹⁶⁹	N/A infections, N/A central-line days ¹⁶⁹	N/A ¹⁶⁹
Description Central Line-associated Bloodstream Infection (CLABSI) data in the Medical-Surgical Pediatric ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2018 - Q4 2018 Result N/A infections, N/A central-line days ¹⁶⁹ Rating SIR: N/A ¹⁶⁹	N/A infections, N/A central-line days ¹⁶⁹	N/A ¹⁶⁹
Q1 2017 - Q4 2017 Result N/A infections, N/A central-line days ¹⁶⁹ Rating SIR: N/A ¹⁶⁹	N/A infections, N/A central-line days ¹⁶⁹	N/A ¹⁶⁹
Q1 2016 - Q4 2016 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2015 - Q4 2015 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2014 - Q4 2014 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2013 - Q4 2013 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2012 - Q4 2012 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2011 - Q4 2011 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2010 - Q4 2010 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2010 - Q2 2010 Result N/A infections, N/A central-line days ³⁸ Rating SIR: 0.00 ³⁸	N/A infections, N/A central-line days ³⁸	0.00 ³⁸

NICU CLABSI

NICU CLABSI Measure	Result	SIR
Level III Neonatal ICU Q1 2019 - Q4 2019 Result N/A infections, N/A central-line days ¹⁶⁹ Rating SIR: N/A ¹⁶⁹	N/A infections, N/A central-line days ¹⁶⁹	N/A ¹⁶⁹
Description Central Line-associated Bloodstream Infection data in the Level III Neonatal ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2018 - Q4 2018 Result N/A infections, N/A central-line days ¹⁶⁹ Rating SIR: N/A ¹⁶⁹	N/A infections, N/A central-line days ¹⁶⁹	N/A ¹⁶⁹
Q1 2017 - Q4 2017 Result N/A infections, N/A central-line days ¹⁶⁹ Rating SIR: N/A ¹⁶⁹	N/A infections, N/A central-line days ¹⁶⁹	N/A ¹⁶⁹
Q1 2016 - Q4 2016 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2015 - Q4 2015 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2014 - Q4 2014 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2013 - Q4 2013 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2012 - Q4 2012 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2011 - Q4 2011 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2010 - Q4 2010 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2010 - Q2 2010 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹

Surgical Site Infections (SSIs)

Presented below are data for surgical site infections associated with coronary artery bypass graft surgery (CABG) and total knee replacement surgery (KPROs) using the Standardized Infection Ratio (SIR) . Superficial and secondary surgical site infections are not included in the summary data below. Statewide summaries of surgical site infection data arranged by surgical procedure ( CABG , KPRO ) and hospital are also included.

Statistical Significance

Statistically significantly better than the national average or performing at the best possible rate

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
45	Complete Reporting: Zero infections. Number of predicted LabID events too low to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
48	No Target Procedures Performed
49	Complete Reporting: 20 or Fewer Procedures Performed
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
155	Complete Reporting: 20 or Fewer Procedures Performed
169	Exempt: No Licensed ICU Beds

Immunization Practices

Illinois hospitals are focusing their efforts on boosting immunization treatments and strengthening patient safety protocols. The objective is not merely achieving statistical success, but also enhancing the quality of care and patient well-being.

Data on immunization measures in Illinois hospitals is available through the Medicare comparison tool at medicare.gov/hospitalcompare . This tool provides valuable insights, allowing patients and their families to gauge the quality of care and safety practices at local hospitals, helping them make informed healthcare decisions.

In the realm of Patient Safety, a host of measures are assessed, with risk-adjusted rates available for each. These measures encompass various aspects of patient care and treatment outcomes. However, interpreting these metrics requires an understanding of the complexity and context-specific nature of healthcare.

Immunization

These indicators are used to measure immunization treatments at hospitals. This data comes from medicare.gov/hospitalcompare .

Measure	Result
Healthcare workers given influenza vaccination Q4 2022 - Q1 2023 Result N/A %	N/A %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 42.00 %	42.00 %
Q4 2020 - Q1 2021 Result 48.00 %	48.00 %
Q4 2019 - Q1 2020 Result 68.00 %	68.00 %
Q4 2018 - Q1 2019 Result 74.00 %	74.00 %
Q4 2017 - Q1 2018 Result 94.00 %	94.00 %

Patient Safety

Statistical Significance

Statistically significantly better than the national average or performing at the best possible rate

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
45	Complete Reporting: Zero infections. Number of predicted LabID events too low to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
48	No Target Procedures Performed
49	Complete Reporting: 20 or Fewer Procedures Performed
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
155	Complete Reporting: 20 or Fewer Procedures Performed
169	Exempt: No Licensed ICU Beds

Measure	Risk-Adjusted Rate
Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) Q4 2020 - Q3 2021 Rating SIR: 6.72	6.72
Description The number of cases of deep vein thrombosis or pulmonary embolism per 1,000 surgical discharges (PSI 12). Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 7.83	7.83
Q4 2018 - Q3 2019 Rating SIR: 2.80	2.80
Q2 2018 - Q1 2019 Rating SIR: 7.17	7.17
Q1 2015 - Q4 2015 Rating SIR: 6.93	6.93
Q4 2014 - Q3 2015 Rating SIR: 8.72	8.72
Q1 2014 - Q4 2014 Rating SIR: 3.27	3.27
Q4 2013 - Q3 2014 Rating SIR: 2.85	2.85
Q1 2013 - Q4 2013 Rating SIR: 1.24	1.24
Q3 2012 - Q2 2013 Rating SIR: 2.97	2.97
Q1 2012 - Q4 2012 Rating SIR: 5.90	5.90
Q4 2011 - Q3 2012 Rating SIR: 4.99	4.99
Q2 2011 - Q1 2012 Rating SIR: 0.52	0.52
Q1 2011 - Q4 2011 Rating SIR: 2.36	2.36
Q4 2010 - Q3 2011 Rating SIR: 3.19	3.19
Q1 2010 - Q4 2010 Rating SIR: 1.74	1.74
Q4 2009 - Q3 2010 Rating SIR: 1.40	1.40
Q1 2009 - Q4 2009 Rating SIR: 1.80	1.80
Q3 2008 - Q2 2009 Rating SIR: 0.60	0.60
Q1 2008 - Q4 2008 Rating SIR: 1.70	1.70
Wound Complications in Abdominal Wall Surgery Q4 2020 - Q3 2021 Rating SIR: 8.62	8.62
Description The number of cases of reclosure of postoperative disruption of abdominal wall per 1,000 cases of abdominopelvic surgery. (PSI 14) Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 2.82	2.82
Q4 2013 - Q3 2014 Rating SIR: 2.56	2.56
Q1 2013 - Q4 2013 Rating SIR: 2.56	2.56
Q3 2012 - Q2 2013 Rating SIR: 4.85	4.85
Q1 2012 - Q4 2012 Rating SIR: 2.59	2.59
Q4 2011 - Q3 2012 Rating SIR: 2.95	2.95
Q2 2011 - Q1 2012 Rating SIR: 1.45	1.45
Q1 2011 - Q4 2011 Rating SIR: 2.65	2.65
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.24	0.24
Accidental Puncture and Laceration Q4 2020 - Q3 2021 Rating SIR: 1.49	1.49
Description The number of cases of accidental cut, puncture, perforation, or laceration during procedure per 1,000 discharges. (PSI 15) Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 1.39	1.39
Q4 2014 - Q3 2015 Rating SIR: 1.43	1.43
Q1 2014 - Q4 2014 Rating SIR: 1.69	1.69
Q4 2013 - Q3 2014 Rating SIR: 1.33	1.33
Q1 2013 - Q4 2013 Rating SIR: 1.10	1.10
Q3 2012 - Q2 2013 Rating SIR: 0.60	0.60
Q1 2012 - Q4 2012 Rating SIR: 1.17	1.17
Q4 2011 - Q3 2012 Rating SIR: 1.12	1.12
Q2 2011 - Q1 2012 Rating SIR: 0.11	0.11
Q1 2011 - Q4 2011 Rating SIR: 0.44	0.44
Q4 2010 - Q3 2011 Rating SIR: 0.74	0.74
Q1 2010 - Q4 2010 Rating SIR: 0.45	0.45
Q4 2009 - Q3 2010 Rating SIR: 0.48	0.48
Q1 2009 - Q4 2009 Rating SIR: 0.45	0.45
Q3 2008 - Q2 2009 Rating SIR: 0.10	0.10
Q1 2008 - Q4 2008 Rating SIR: 0.30	0.30
Collapsed Lung caused by Medical Care Q4 2020 - Q3 2021 Rating SIR: 0.92	0.92
Description This measure is used to assess the number of cases of collapsed lung caused by medical care per 1,000 patients. (PSI 06) Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.56	0.56
Q4 2014 - Q3 2015 Rating SIR: 0.39	0.39
Q1 2014 - Q4 2014 Rating SIR: 0.33	0.33
Q4 2013 - Q3 2014 Rating SIR: 0.54	0.54
Q1 2013 - Q4 2013 Rating SIR: 0.34	0.34
Q3 2012 - Q2 2013 Rating SIR: 0.17	0.17
Q1 2012 - Q4 2012 Rating SIR: 0.00	0.00
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 0.04	0.04
Q1 2011 - Q4 2011 Rating SIR: 4.22	4.22
Q4 2010 - Q3 2011 Rating SIR: 0.70	0.70
Q1 2010 - Q4 2010 Rating SIR: 0.14	0.14
Q4 2009 - Q3 2010 Rating SIR: 0.71	0.71
Q1 2009 - Q4 2009 Rating SIR: 0.70	0.70
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.10	0.10
Postoperative Hemorrhage or Hematoma Q4 2020 - Q3 2021 Rating SIR: 7.01	7.01
Description The number of cases of hematoma or hemorrhage requiring a procedure per 1,000 surgical discharges. (PSI 09) Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 3.62	3.62
Q4 2018 - Q3 2019 Rating SIR: 1.88	1.88
Q2 2018 - Q1 2019 Rating SIR: 2.05	2.05
Q1 2015 - Q4 2015 Rating SIR: 7.43	7.43
Q4 2014 - Q3 2015 Rating SIR: 5.59	5.59
Q1 2014 - Q4 2014 Rating SIR: 7.63	7.63
Q4 2013 - Q3 2014 Rating SIR: 9.59	9.59
Q1 2013 - Q4 2013 Rating SIR: 6.65	6.65
Q3 2012 - Q2 2013 Rating SIR: 6.52	6.52
Q1 2012 - Q4 2012 Rating SIR: 7.95	7.95
Q4 2011 - Q3 2012 Rating SIR: 2.79	2.79
Q2 2011 - Q1 2012 Rating SIR: 6.91	6.91
Q1 2011 - Q4 2011 Rating SIR: 4.39	4.39
Q4 2010 - Q3 2011 Rating SIR: 6.58	6.58
Q1 2010 - Q4 2010 Rating SIR: 7.01	7.01
Q4 2009 - Q3 2010 Rating SIR: 4.74	4.74
Q1 2009 - Q4 2009 Rating SIR: 5.25	5.25
Q3 2008 - Q2 2009 Rating SIR: 0.48	0.48
Q1 2008 - Q4 2008 Rating SIR: 0.57	0.57
Postoperative Respiratory Failure Q4 2020 - Q3 2021 Rating SIR: 29.25	29.25
Description The number of cases of acute respiratory failure per 1,000 elective surgical discharges. (PSI 11) Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 17.94	17.94
Q4 2018 - Q3 2019 Rating SIR: 11.56	11.56
Q2 2018 - Q1 2019 Rating SIR: 11.16	11.16
Q1 2015 - Q4 2015 Rating SIR: 11.13	11.13
Q4 2014 - Q3 2015 Rating SIR: 30.49	30.49
Q1 2014 - Q4 2014 Rating SIR: 26.49	26.49
Q4 2013 - Q3 2014 Rating SIR: 20.91	20.91
Q1 2013 - Q4 2013 Rating SIR: 12.15	12.15
Q3 2012 - Q2 2013 Rating SIR: 6.51	6.51
Q1 2012 - Q4 2012 Rating SIR: 20.16	20.16
Q4 2011 - Q3 2012 Rating SIR: 26.64	26.64
Q2 2011 - Q1 2012 Rating SIR: 18.37	18.37
Q1 2011 - Q4 2011 Rating SIR: 14.88	14.88
Q4 2010 - Q3 2011 Rating SIR: 15.55	15.55
Q1 2010 - Q4 2010 Rating SIR: 9.95	9.95
Q4 2009 - Q3 2010 Rating SIR: 35.64	35.64
Q1 2009 - Q4 2009 Rating SIR: 33.23	33.23
Q3 2008 - Q2 2009 Rating SIR: 1.90	1.90
Q1 2008 - Q4 2008 Rating SIR: 1.87	1.87
Postoperative Hip Fracture Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Description The number of cases of in-hospital hip fracture per 1,000 surgical discharges(PSI 08). Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.00	0.00
Q1 2013 - Q4 2013 Rating SIR: 0.00	0.00
Q3 2012 - Q2 2013 Rating SIR: 0.00	0.00
Q1 2012 - Q4 2012 Rating SIR: 0.00	0.00
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 0.00	0.00
Q1 2011 - Q4 2011 Rating SIR: 0.00	0.00
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00
Pressure Ulcer Q4 2020 - Q3 2021 Rating SIR: 0.44	0.44
Description The number of cases of pressure ulcer per 1,000 discharges with a length of stay greater than 4 days (PSI 03). Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 0.73	0.73
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.32	0.32
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.65	0.65
Q1 2013 - Q4 2013 Rating SIR: 0.60	0.60
Q3 2012 - Q2 2013 Rating SIR: 0.00	0.00
Q1 2012 - Q4 2012 Rating SIR: 0.00	0.00
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 0.00	0.00
Q1 2011 - Q4 2011 Rating SIR: 0.00	0.00
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 2.15	2.15
Q3 2008 - Q2 2009 Rating SIR: 0.25	0.25
Q1 2008 - Q4 2008 Rating SIR: 1.36	1.36
Postoperative Sepsis Q4 2020 - Q3 2021 Rating SIR: 10.96	10.96
Description The number of cases of sepsis per 1,000 elective surgery patients with a length of stay of 4 days or more (PSI 13). Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 3.66	3.66
Q4 2018 - Q3 2019 Rating SIR: 5.33	5.33
Q2 2018 - Q1 2019 Rating SIR: 7.92	7.92
Q1 2015 - Q4 2015 Rating SIR: 12.17	12.17
Q4 2014 - Q3 2015 Rating SIR: 28.46	28.46
Q1 2014 - Q4 2014 Rating SIR: 44.25	44.25
Q4 2013 - Q3 2014 Rating SIR: 46.83	46.83
Q1 2013 - Q4 2013 Rating SIR: 56.57	56.57
Q3 2012 - Q2 2013 Rating SIR: 42.06	42.06
Q1 2012 - Q4 2012 Rating SIR: 11.64	11.64
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 8.05	8.05
Q1 2011 - Q4 2011 Rating SIR: 7.40	7.40
Q4 2010 - Q3 2011 Rating SIR: 5.51	5.51
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.57	0.57
Q1 2008 - Q4 2008 Rating SIR: 1.90	1.90
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Description This measure is used to assess the number of cases of specified physiological or metabolic derangement per 1,000 elective surgical discharges with an operating room procedure. (PSI 10) Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 3.08	3.08
Q1 2014 - Q4 2014 Rating SIR: 2.27	2.27
Q4 2013 - Q3 2014 Rating SIR: 1.82	1.82
Q1 2013 - Q4 2013 Rating SIR: 0.00	0.00
Q3 2012 - Q2 2013 Rating SIR: 0.00	0.00
Q1 2012 - Q4 2012 Rating SIR: 0.00	0.00
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 0.00	0.00
Q1 2011 - Q4 2011 Rating SIR: 0.00	0.00
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 2.91	2.91
Q3 2008 - Q2 2009 Rating SIR: 0.23	0.23
Q1 2008 - Q4 2008 Rating SIR: 0.11	0.11

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 2 infections, 23079 patient days Rating SIR: 1.10	2 infections, 23079 patient days	1.10
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 2 infections, 27866 patient days Rating SIR: 1.22	2 infections, 27866 patient days	1.22
Q1 2021 - Q4 2021 Result 1 infections, 27412 patient days Rating SIR: 0.79	1 infections, 27412 patient days	0.79
Q1 2020 - Q4 2020 Result 3 infections, 28103 patient days Rating SIR: 1.72	3 infections, 28103 patient days	1.72
Q1 2019 - Q4 2019 Result 0 infections, 28648 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 28648 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 1 infections, 28581 patient days Rating SIR: 0.72	1 infections, 28581 patient days	0.72
Q1 2017 - Q4 2017 Result 2 infections, 28067 patient days Rating SIR: 1.26	2 infections, 28067 patient days	1.26
Q1 2016 - Q4 2016 Result 0 infections, 29141 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 29141 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 0 infections, 31408 patient days Rating SIR: 0.00	0 infections, 31408 patient days	0.00
Q1 2014 - Q4 2014 Result 2 infections, 33492 patient days Rating SIR: 0.54	2 infections, 33492 patient days	0.54
Q1 2013 - Q4 2013 Result 1 infections, 34004 patient days Rating SIR: 0.22	1 infections, 34004 patient days	0.22
Q1 2012 - Q4 2012 Result 4 infections, 27288 patient days Rating SIR: 1.28	4 infections, 27288 patient days	1.28
Q1 2012 - Q2 2012 Result 2 infections, 13740 patient days Rating SIR: 1.46	2 infections, 13740 patient days	1.46
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 12 infections, 22347 patient days Rating SIR: 0.92	12 infections, 22347 patient days	0.92
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 20 infections, 27218 patient days Rating SIR: 1.15	20 infections, 27218 patient days	1.15
Q1 2021 - Q4 2021 Result 7 infections, 25700 patient days Rating SIR: 0.49	7 infections, 25700 patient days	0.49
Q1 2020 - Q4 2020 Result 18 infections, 26714 patient days Rating SIR: 1.23	18 infections, 26714 patient days	1.23
Q1 2019 - Q4 2019 Result 9 infections, 27484 patient days Rating SIR: 0.50	9 infections, 27484 patient days	0.50
Q1 2018 - Q4 2018 Result 22 infections, 27168 patient days Rating SIR: 1.16	22 infections, 27168 patient days	1.16
Q1 2017 - Q4 2017 Result 15 infections, 26718 patient days Rating SIR: 0.84	15 infections, 26718 patient days	0.84
Q1 2016 - Q4 2016 Result 23 infections, 26956 patient days Rating SIR: 1.11	23 infections, 26956 patient days	1.11
Q1 2015 - Q4 2015 Result 23 infections, 30648 patient days Rating SIR: 0.81	23 infections, 30648 patient days	0.81
Q1 2014 - Q4 2014 Result 31 infections, 30216 patient days Rating SIR: 1.31	31 infections, 30216 patient days	1.31
Q1 2013 - Q4 2013 Result 18 infections, 29935 patient days Rating SIR: 0.68	18 infections, 29935 patient days	0.68
Q1 2012 - Q4 2012 Result 22 infections, 27288 patient days Rating SIR: 1.20	22 infections, 27288 patient days	1.20

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2023 - Q4 2023 Result 4 infections, 1610 central-line days Rating SIR: 2.54	4 infections, 1610 central-line days	2.54
Description Central Line-associated Bloodstream Infection data in the Adult Medical/Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 4 infections, 2603 central-line days Rating SIR: 1.36	4 infections, 2603 central-line days	1.36
Q1 2021 - Q4 2021 Result 7 infections, 2445 central-line days Rating SIR: 2.92	7 infections, 2445 central-line days	2.92
Q1 2020 - Q4 2020 Result 3 infections, 2084 central-line days Rating SIR: 1.47	3 infections, 2084 central-line days	1.47
Q1 2019 - Q4 2019 Result 3 infections, 1546 central-line days Rating SIR: 1.98	3 infections, 1546 central-line days	1.98
Q1 2018 - Q4 2018 Result 0 infections, 1653 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1653 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 2 infections, 1430 central-line days Rating SIR: 1.43	2 infections, 1430 central-line days	1.43
Q1 2016 - Q4 2016 Result 0 infections, 1437 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1437 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 1 infections, 1387 central-line days Rating SIR: 0.34	1 infections, 1387 central-line days	0.34
Q1 2014 - Q4 2014 Result 0 infections, 1582 central-line days Rating SIR: 0.00	0 infections, 1582 central-line days	0.00
Q1 2013 - Q4 2013 Result 0 infections, 1547 central-line days Rating SIR: 0.00	0 infections, 1547 central-line days	0.00
Q1 2012 - Q4 2012 Result 2 infections, 1593 central-line days Rating SIR: 0.60	2 infections, 1593 central-line days	0.60
Q1 2011 - Q4 2011 Result 1 infections, 2077 central-line days Rating SIR: 0.32	1 infections, 2077 central-line days	0.32
Q1 2010 - Q4 2010 Result 1 infections, 2407 central-line days Rating SIR: 0.28	1 infections, 2407 central-line days	0.28
Q1 2009 - Q4 2009 Result 0 infections, 2588 central-line days Rating SIR: 0.00	0 infections, 2588 central-line days	0.00
Q1 2009 - Q2 2009 Result 0 infections, 1494 central-line days Rating SIR: 0.00	0 infections, 1494 central-line days	0.00

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 0 infections, 62 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 62 procedures ¹¹⁸	N/A ¹¹⁸
Description Surgical Site Infections Associated with Total Knee Replacement Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2019 - Q4 2019 Result 0 infections, 74 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 74 procedures ¹⁵³	N/A ¹⁵³
Q1 2018 - Q4 2018 Result 0 infections, 67 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 67 procedures ¹⁵³	N/A ¹⁵³
Q1 2017 - Q4 2017 Result 0 infections, 45 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 45 procedures ¹⁵³	N/A ¹⁵³
Q1 2016 - Q4 2016 Result 0 infections, 52 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 52 procedures ¹⁵³	N/A ¹⁵³
Q1 2015 - Q4 2015 Result 0 infections, 69 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 69 procedures ¹⁵³	N/A ¹⁵³
Q1 2014 - Q4 2014 Result 0 infections, 60 procedures Rating SIR: N/A	0 infections, 60 procedures	N/A
Q3 2013 - Q2 2014 Result 0 infections, 69 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 69 procedures ¹¹⁸	N/A ¹¹⁸
Q3 2012 - Q2 2013 Result 0 infections, 95 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 95 procedures ¹¹⁸	N/A ¹¹⁸
Q3 2011 - Q2 2012 Result 0 infections, 135 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 135 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 1 infections, 123 procedures ⁴⁷ Rating SIR: N/A ⁴⁷	1 infections, 123 procedures ⁴⁷	N/A ⁴⁷
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Description Surgical Site Infections Associated with Coronary Artery Bypass Graft Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2019 - Q4 2019 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2018 - Q4 2018 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2016 - Q4 2016 Result 0 infections, 8 procedures ⁴⁹ Rating SIR: N/A ⁴⁹	0 infections, 8 procedures ⁴⁹	N/A ⁴⁹
Q1 2015 - Q4 2015 Result N/A infections, N/A procedures ¹⁵⁵ Rating SIR: N/A ¹⁵⁵	N/A infections, N/A procedures ¹⁵⁵	N/A ¹⁵⁵
Q1 2014 - Q4 2014 Result 0 infections, 16 procedures Rating SIR: N/A	0 infections, 16 procedures	N/A
Q3 2013 - Q2 2014 Result 0 infections, 24 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 24 procedures ¹¹⁸	N/A ¹¹⁸
Q3 2012 - Q2 2013 Result 0 infections, 26 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 26 procedures ¹¹⁸	N/A ¹¹⁸
Q3 2011 - Q2 2012 Result 1 infections, 32 procedures ⁴⁷ Rating SIR: N/A ⁴⁷	1 infections, 32 procedures ⁴⁷	N/A ⁴⁷
Q3 2010 - Q2 2011 Result 0 infections, 46 procedures ⁴⁵ Rating SIR: N/A ⁴⁵	0 infections, 46 procedures ⁴⁵	N/A ⁴⁵