Advocate Good Shepherd Hospital

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
32	Complete Reporting: Unit Operational Limited Time
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
154	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
32	Complete Reporting: Unit Operational Limited Time
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
154	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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

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
32	Complete Reporting: Unit Operational Limited Time
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
154	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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 83.00 %	83.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 97.00 %	97.00 %
Q4 2020 - Q1 2021 Result 97.00 %	97.00 %
Q4 2019 - Q1 2020 Result 97.00 %	97.00 %
Q4 2018 - Q1 2019 Result 95.00 %	95.00 %
Q4 2017 - Q1 2018 Result 97.00 %	97.00 %

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
32	Complete Reporting: Unit Operational Limited Time
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
154	Complete Reporting: Number of predicted events too low to calculate a precise SIR
169	Exempt: No Licensed ICU Beds

Measure	Risk-Adjusted Rate
Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) Q4 2021 - Q3 2022 Rating SIR: 0.93	0.93
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 2020 - Q3 2021 Rating SIR: 2.46	2.46
Q4 2019 - Q3 2020 Rating SIR: 0.86	0.86
Q4 2018 - Q3 2019 Rating SIR: 1.46	1.46
Q2 2018 - Q1 2019 Rating SIR: 3.40	3.40
Q1 2015 - Q4 2015 Rating SIR: 3.84	3.84
Q4 2014 - Q3 2015 Rating SIR: 2.54	2.54
Q1 2014 - Q4 2014 Rating SIR: 2.21	2.21
Q4 2013 - Q3 2014 Rating SIR: 2.02	2.02
Q1 2013 - Q4 2013 Rating SIR: 0.40	0.40
Q3 2012 - Q2 2013 Rating SIR: 0.38	0.38
Q1 2012 - Q4 2012 Rating SIR: 2.77	2.77
Q4 2011 - Q3 2012 Rating SIR: 3.27	3.27
Q2 2011 - Q1 2012 Rating SIR: 0.35	0.35
Q1 2011 - Q4 2011 Rating SIR: 2.07	2.07
Q4 2010 - Q3 2011 Rating SIR: 1.95	1.95
Q1 2010 - Q4 2010 Rating SIR: 4.64	4.64
Q4 2009 - Q3 2010 Rating SIR: 4.20	4.20
Q1 2009 - Q4 2009 Rating SIR: 5.24	5.24
Q3 2008 - Q2 2009 Rating SIR: 7.10	7.10
Q1 2008 - Q4 2008 Rating SIR: 6.40	6.40
Wound Complications in Abdominal Wall Surgery Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
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 2020 - Q3 2021 Rating SIR: 0.00	0.00
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: 2.38	2.38
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: 0.24	0.24
Q1 2008 - Q4 2008 Rating SIR: 0.43	0.43
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 1.04	1.04
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 2020 - Q3 2021 Rating SIR: 0.87	0.87
Q4 2019 - Q3 2020 Rating SIR: 1.18	1.18
Q4 2018 - Q3 2019 Rating SIR: 0.48	0.48
Q2 2018 - Q1 2019 Rating SIR: 0.50	0.50
Q1 2015 - Q4 2015 Rating SIR: 1.42	1.42
Q4 2014 - Q3 2015 Rating SIR: 1.14	1.14
Q1 2014 - Q4 2014 Rating SIR: 1.64	1.64
Q4 2013 - Q3 2014 Rating SIR: 1.26	1.26
Q1 2013 - Q4 2013 Rating SIR: 1.10	1.10
Q3 2012 - Q2 2013 Rating SIR: 1.53	1.53
Q1 2012 - Q4 2012 Rating SIR: 1.67	1.67
Q4 2011 - Q3 2012 Rating SIR: 1.53	1.53
Q2 2011 - Q1 2012 Rating SIR: 0.12	0.12
Q1 2011 - Q4 2011 Rating SIR: 1.37	1.37
Q4 2010 - Q3 2011 Rating SIR: 1.28	1.28
Q1 2010 - Q4 2010 Rating SIR: 1.43	1.43
Q4 2009 - Q3 2010 Rating SIR: 1.92	1.92
Q1 2009 - Q4 2009 Rating SIR: 1.48	1.48
Q3 2008 - Q2 2009 Rating SIR: 0.90	0.90
Q1 2008 - Q4 2008 Rating SIR: 1.00	1.00
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
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 2020 - Q3 2021 Rating SIR: 0.11	0.11
Q4 2019 - Q3 2020 Rating SIR: 0.12	0.12
Q4 2018 - Q3 2019 Rating SIR: 0.23	0.23
Q2 2018 - Q1 2019 Rating SIR: 0.11	0.11
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.14	0.14
Q1 2014 - Q4 2014 Rating SIR: 0.25	0.25
Q4 2013 - Q3 2014 Rating SIR: 0.28	0.28
Q1 2013 - Q4 2013 Rating SIR: 0.43	0.43
Q3 2012 - Q2 2013 Rating SIR: 0.28	0.28
Q1 2012 - Q4 2012 Rating SIR: 0.27	0.27
Q4 2011 - Q3 2012 Rating SIR: 0.27	0.27
Q2 2011 - Q1 2012 Rating SIR: 0.06	0.06
Q1 2011 - Q4 2011 Rating SIR: 3.19	3.19
Q4 2010 - Q3 2011 Rating SIR: 0.31	0.31
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: 0.45	0.45
Q3 2008 - Q2 2009 Rating SIR: 0.20	0.20
Q1 2008 - Q4 2008 Rating SIR: 0.10	0.10
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 1.38	1.38
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 2020 - Q3 2021 Rating SIR: 4.23	4.23
Q4 2019 - Q3 2020 Rating SIR: 2.20	2.20
Q4 2018 - Q3 2019 Rating SIR: 1.65	1.65
Q2 2018 - Q1 2019 Rating SIR: 0.83	0.83
Q1 2015 - Q4 2015 Rating SIR: 1.79	1.79
Q4 2014 - Q3 2015 Rating SIR: 3.15	3.15
Q1 2014 - Q4 2014 Rating SIR: 3.39	3.39
Q4 2013 - Q3 2014 Rating SIR: 3.52	3.52
Q1 2013 - Q4 2013 Rating SIR: 2.11	2.11
Q3 2012 - Q2 2013 Rating SIR: 2.37	2.37
Q1 2012 - Q4 2012 Rating SIR: 3.81	3.81
Q4 2011 - Q3 2012 Rating SIR: 2.84	2.84
Q2 2011 - Q1 2012 Rating SIR: 0.77	0.77
Q1 2011 - Q4 2011 Rating SIR: 2.58	2.58
Q4 2010 - Q3 2011 Rating SIR: 0.40	0.40
Q1 2010 - Q4 2010 Rating SIR: 1.18	1.18
Q4 2009 - Q3 2010 Rating SIR: 1.23	1.23
Q1 2009 - Q4 2009 Rating SIR: 1.16	1.16
Q3 2008 - Q2 2009 Rating SIR: 0.24	0.24
Q1 2008 - Q4 2008 Rating SIR: 0.24	0.24
Postoperative Respiratory Failure Q4 2021 - Q3 2022 Rating SIR: 10.75	10.75
Description The number of cases of acute respiratory failure per 1,000 elective surgical discharges. (PSI 11) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 17.94	17.94
Q4 2019 - Q3 2020 Rating SIR: 7.31	7.31
Q4 2018 - Q3 2019 Rating SIR: 3.83	3.83
Q2 2018 - Q1 2019 Rating SIR: 6.63	6.63
Q1 2015 - Q4 2015 Rating SIR: 11.15	11.15
Q4 2014 - Q3 2015 Rating SIR: 10.44	10.44
Q1 2014 - Q4 2014 Rating SIR: 6.92	6.92
Q4 2013 - Q3 2014 Rating SIR: 4.18	4.18
Q1 2013 - Q4 2013 Rating SIR: 7.97	7.97
Q3 2012 - Q2 2013 Rating SIR: 6.61	6.61
Q1 2012 - Q4 2012 Rating SIR: 9.19	9.19
Q4 2011 - Q3 2012 Rating SIR: 9.08	9.08
Q2 2011 - Q1 2012 Rating SIR: 6.14	6.14
Q1 2011 - Q4 2011 Rating SIR: 5.59	5.59
Q4 2010 - Q3 2011 Rating SIR: 6.58	6.58
Q1 2010 - Q4 2010 Rating SIR: 4.23	4.23
Q4 2009 - Q3 2010 Rating SIR: 12.31	12.31
Q1 2009 - Q4 2009 Rating SIR: 10.33	10.33
Q3 2008 - Q2 2009 Rating SIR: 1.01	1.01
Q1 2008 - Q4 2008 Rating SIR: 0.85	0.85
Postoperative Hip Fracture Q4 2021 - Q3 2022 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 2020 - Q3 2021 Rating SIR: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.12	0.12
Q2 2018 - Q1 2019 Rating SIR: 0.13	0.13
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 2021 - Q3 2022 Rating SIR: 0.00	0.00
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 2020 - Q3 2021 Rating SIR: 0.19	0.19
Q4 2019 - Q3 2020 Rating SIR: 0.21	0.21
Q4 2018 - Q3 2019 Rating SIR: 0.33	0.33
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.39	0.39
Q4 2014 - Q3 2015 Rating SIR: 0.44	0.44
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.92	0.92
Q1 2013 - Q4 2013 Rating SIR: 0.96	0.96
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: 0.05	0.05
Q1 2008 - Q4 2008 Rating SIR: 0.04	0.04
Postoperative Sepsis Q4 2021 - Q3 2022 Rating SIR: 5.98	5.98
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 2020 - Q3 2021 Rating SIR: 4.79	4.79
Q4 2019 - Q3 2020 Rating SIR: 3.78	3.78
Q4 2018 - Q3 2019 Rating SIR: 5.89	5.89
Q2 2018 - Q1 2019 Rating SIR: 6.12	6.12
Q1 2015 - Q4 2015 Rating SIR: 4.40	4.40
Q4 2014 - Q3 2015 Rating SIR: 9.21	9.21
Q1 2014 - Q4 2014 Rating SIR: 3.85	3.85
Q4 2013 - Q3 2014 Rating SIR: 3.89	3.89
Q1 2013 - Q4 2013 Rating SIR: 3.69	3.69
Q3 2012 - Q2 2013 Rating SIR: 0.00	0.00
Q1 2012 - Q4 2012 Rating SIR: 3.93	3.93
Q4 2011 - Q3 2012 Rating SIR: 4.34	4.34
Q2 2011 - Q1 2012 Rating SIR: 4.13	4.13
Q1 2011 - Q4 2011 Rating SIR: 0.00	0.00
Q4 2010 - Q3 2011 Rating SIR: 11.80	11.80
Q1 2010 - Q4 2010 Rating SIR: 9.06	9.06
Q4 2009 - Q3 2010 Rating SIR: 6.48	6.48
Q1 2009 - Q4 2009 Rating SIR: 9.23	9.23
Q3 2008 - Q2 2009 Rating SIR: 0.64	0.64
Q1 2008 - Q4 2008 Rating SIR: 1.90	1.90
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2021 - Q3 2022 Rating SIR: 2.39	2.39
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 2020 - Q3 2021 Rating SIR: 0.49	0.49
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.54	0.54
Q2 2018 - Q1 2019 Rating SIR: 1.30	1.30
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: 0.69	0.69
Q4 2013 - Q3 2014 Rating SIR: 0.69	0.69
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: 0.66	0.66
Q1 2011 - Q4 2011 Rating SIR: 0.65	0.65
Q4 2010 - Q3 2011 Rating SIR: 0.71	0.71
Q1 2010 - Q4 2010 Rating SIR: 0.71	0.71
Q4 2009 - Q3 2010 Rating SIR: 0.69	0.69
Q1 2009 - Q4 2009 Rating SIR: 1.25	1.25
Q3 2008 - Q2 2009 Rating SIR: 0.17	0.17
Q1 2008 - Q4 2008 Rating SIR: 0.16	0.16

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 1 infections, 53634 patient days Rating SIR: 0.39	1 infections, 53634 patient days	0.39
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 4 infections, 53543 patient days Rating SIR: 1.45	4 infections, 53543 patient days	1.45
Q1 2021 - Q4 2021 Result 0 infections, 51175 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 51175 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 1 infections, 46088 patient days Rating SIR: 0.38	1 infections, 46088 patient days	0.38
Q1 2019 - Q4 2019 Result 2 infections, 47737 patient days Rating SIR: 1.00	2 infections, 47737 patient days	1.00
Q1 2018 - Q4 2018 Result 0 infections, 48460 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 48460 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 0 infections, 47085 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 47085 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 0 infections, 48636 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 48636 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 0 infections, 48182 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 48182 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 4 infections, 45872 patient days Rating SIR: 2.02	4 infections, 45872 patient days	2.02
Q1 2013 - Q4 2013 Result 1 infections, 44087 patient days Rating SIR: 0.57	1 infections, 44087 patient days	0.57
Q1 2012 - Q4 2012 Result 1 infections, 46403 patient days Rating SIR: 0.53	1 infections, 46403 patient days	0.53
Q1 2012 - Q2 2012 Result 1 infections, 24134 patient days Rating SIR: 0.41	1 infections, 24134 patient days	0.41
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 6 infections, 50959 patient days Rating SIR: 0.28	6 infections, 50959 patient days	0.28
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 7 infections, 50450 patient days Rating SIR: 0.33	7 infections, 50450 patient days	0.33
Q1 2021 - Q4 2021 Result 2 infections, 48540 patient days Rating SIR: 0.10	2 infections, 48540 patient days	0.10
Q1 2020 - Q4 2020 Result 2 infections, 44133 patient days Rating SIR: 0.11	2 infections, 44133 patient days	0.11
Q1 2019 - Q4 2019 Result 6 infections, 45074 patient days Rating SIR: 0.32	6 infections, 45074 patient days	0.32
Q1 2018 - Q4 2018 Result 24 infections, 46201 patient days Rating SIR: 1.01	24 infections, 46201 patient days	1.01
Q1 2017 - Q4 2017 Result 28 infections, 43110 patient days Rating SIR: 1.18	28 infections, 43110 patient days	1.18
Q1 2016 - Q4 2016 Result 39 infections, 45060 patient days Rating SIR: 1.43	39 infections, 45060 patient days	1.43
Q1 2015 - Q4 2015 Result 37 infections, 44533 patient days Rating SIR: 1.30	37 infections, 44533 patient days	1.30
Q1 2014 - Q4 2014 Result 32 infections, 41905 patient days Rating SIR: 1.26	32 infections, 41905 patient days	1.26
Q1 2013 - Q4 2013 Result 23 infections, 40113 patient days Rating SIR: 0.83	23 infections, 40113 patient days	0.83
Q1 2012 - Q4 2012 Result 37 infections, 41723 patient days Rating SIR: 1.37	37 infections, 41723 patient days	1.37

Adult CLABSI Measure	Result	SIR
Adult Surgical Cardiothoracic ICU Q1 2013 - Q4 2013 Result 0 infections, 1597 central-line days ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 1597 central-line days ⁴⁶	0.00 ⁴⁶
Description Central Line-associated Bloodstream Infection data in the Adult Surgical Cardiothoracic ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2012 - Q4 2012 Result 0 infections, 1553 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 1553 central-line days ⁴³	0.00 ⁴³
Adult Medical/Surgical ICU Q1 2023 - Q4 2023 Result 0 infections, 1140 central-line days Rating SIR: N/A	0 infections, 1140 central-line days	N/A
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 0 infections, 1221 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1221 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2021 - Q4 2021 Result 0 infections, 1165 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1165 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 0 infections, 1078 central-line days Rating SIR: 0.00	0 infections, 1078 central-line days	0.00
Q1 2019 - Q4 2019 Result 0 infections, 833 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 833 central-line days ⁴²	N/A ⁴²
Q1 2018 - Q4 2018 Result 0 infections, 1313 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 1313 central-line days ⁴²	N/A ⁴²
Q1 2017 - Q4 2017 Result 1 infections, 2248 central-line days Rating SIR: 0.59	1 infections, 2248 central-line days	0.59
Q1 2016 - Q4 2016 Result 1 infections, 2931 central-line days Rating SIR: 0.45	1 infections, 2931 central-line days	0.45
Q1 2015 - Q4 2015 Result 1 infections, 2612 central-line days Rating SIR: 0.26	1 infections, 2612 central-line days	0.26
Q1 2014 - Q4 2014 Result 1 infections, 3265 central-line days Rating SIR: 0.20	1 infections, 3265 central-line days	0.20
Q1 2013 - Q4 2013 Result 0 infections, 1338 central-line days ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 1338 central-line days ⁴⁶	0.00 ⁴⁶
Q1 2012 - Q4 2012 Result 4 infections, 1543 central-line days Rating SIR: 1.73	4 infections, 1543 central-line days	1.73
Q1 2011 - Q4 2011 Result 0 infections, 1662 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 1662 central-line days ⁴³	0.00 ⁴³
Q1 2010 - Q4 2010 Result 2 infections, 1629 central-line days Rating SIR: 0.88	2 infections, 1629 central-line days	0.88
Q1 2009 - Q4 2009 Result 4 infections, 2252 central-line days Rating SIR: 1.18	4 infections, 2252 central-line days	1.18
Q1 2009 - Q2 2009 Result 1 infections, 853 central-line days Rating SIR: 1.17	1 infections, 853 central-line days	1.17
Adult Medical ICU Q1 2023 - Q4 2023 Result 1 infections, 1029 central-line days Rating SIR: N/A	1 infections, 1029 central-line days	N/A
Description Central Line-associated Bloodstream Infection data in the Adult Medical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 0 infections, 990 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 990 central-line days ⁴²	N/A ⁴²
Q1 2021 - Q4 2021 Result 0 infections, 923 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 923 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 0 infections, 728 central-line days Rating SIR: N/A	0 infections, 728 central-line days	N/A
Q1 2019 - Q4 2019 Result 1 infections, 906 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 906 central-line days ⁴⁴	N/A ⁴⁴
Q1 2018 - Q4 2018 Result 1 infections, 1277 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 1277 central-line days ⁴⁴	N/A ⁴⁴
Q1 2017 - Q4 2017 Result 0 infections, 584 central-line days ³² Rating SIR: N/A ³²	0 infections, 584 central-line days ³²	N/A ³²

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2016 - Q4 2016 Result 0 infections, 1 central-line days ³³ Rating SIR: N/A ³³	0 infections, 1 central-line days ³³	N/A ³³
Description Central Line-associated Bloodstream Infection data in the Level II/III Neonatal ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2015 - Q4 2015 Result 0 infections, 6 central-line days ³³ Rating SIR: N/A ³³	0 infections, 6 central-line days ³³	N/A ³³
Q1 2014 - Q4 2014 Result 0 infections, 0 central-line days ³³ Rating SIR: N/A ³³	0 infections, 0 central-line days ³³	N/A ³³
Q1 2013 - Q4 2013 Result 0 infections, 22 central-line days ³³ Rating SIR: N/A ³³	0 infections, 22 central-line days ³³	N/A ³³
Q1 2012 - Q4 2012 Result 0 infections, 28 central-line days ³³ Rating SIR: 0.00 ³³	0 infections, 28 central-line days ³³	0.00 ³³
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 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

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 1 infections, 271 procedures Rating SIR: 0.80	1 infections, 271 procedures	0.80
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 1 infections, 340 procedures Rating SIR: 0.61	1 infections, 340 procedures	0.61
Q1 2018 - Q4 2018 Result 3 infections, 328 procedures Rating SIR: 2.31	3 infections, 328 procedures	2.31
Q1 2017 - Q4 2017 Result 0 infections, 300 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 300 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 0 infections, 301 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 301 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 0 infections, 325 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 325 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 2 infections, 256 procedures Rating SIR: 1.32	2 infections, 256 procedures	1.32
Q3 2013 - Q2 2014 Result 0 infections, 259 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 259 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2012 - Q2 2013 Result 0 infections, 206 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 206 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 0 infections, 210 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 210 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 0 infections, 179 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 179 procedures ⁴⁶	0.00 ⁴⁶
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 2 infections, 116 procedures ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	2 infections, 116 procedures ¹⁵⁴	N/A ¹⁵⁴
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 1 infections, 122 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 122 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2018 - Q4 2018 Result 0 infections, 137 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 137 procedures ¹⁵³	N/A ¹⁵³
Q1 2016 - Q4 2016 Result 0 infections, 125 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 125 procedures ¹⁵³	N/A ¹⁵³
Q1 2015 - Q4 2015 Result 5 infections, 152 procedures Rating SIR: 3.48	5 infections, 152 procedures	3.48
Q1 2014 - Q4 2014 Result 0 infections, 126 procedures Rating SIR: 0.00	0 infections, 126 procedures	0.00
Q3 2013 - Q2 2014 Result 0 infections, 121 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 121 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2012 - Q2 2013 Result 0 infections, 97 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 97 procedures ¹¹⁸	N/A ¹¹⁸
Q3 2011 - Q2 2012 Result 0 infections, 125 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 125 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 0 infections, 147 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 147 procedures ⁴⁶	0.00 ⁴⁶