Quality Core Measures at Bayhealth
Bayhealth is committed to providing high quality healthcare services to the communities we serve.
By measuring the care we provide, we are able to identify opportunities for improvement. We measure the quality of our care through a survey. The data is collected by the Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) and available on the Hospital Compare website.
The table below shows how Bayhealth performed in comparison with the U.S. average and the Delaware average for the time periods listed below.
Heart Attack or Chest Pain Process of Care Measures
|
Average number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital (a lower number of minutes is better)
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
60 minutes
|
|
Delaware Average
|
54 minutes
|
|
Bayhealth Medical Center
|
61 minutes
|
|
Average number of minutes before outpatients with chest pain or possible heart attack got an ECG (a lower number of minutes is better)
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
8 minutes
|
|
Delaware Average
|
7 minutes
|
|
Bayhealth Medical Center
|
7 minutes
|
|
Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival (higher numbers are better)
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
96%
|
|
Delaware Average
|
97%
|
|
Bayhealth Medical Center
|
94%
|
|
Heart attack patients given aspirin at arrival
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
99%
|
|
Delaware Average
|
99%
|
|
Bayhealth Medical Center
|
99%
|
|
Heart attack patients given aspirin at discharge
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
99%
|
|
Delaware Average
|
99%
|
|
Bayhealth Medical Center
|
100%
|
|
Heart attack patients given ACE inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
97%
|
|
Delaware Average
|
97%
|
|
Bayhealth Medical Center
|
100%
|
|
Heart attack patients given smoking cessation advice/counseling
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
100%
|
|
Delaware Average
|
100%
|
|
Bayhealth Medical Center
|
99%
|
|
Heart attack patients given beta blocker at discharge
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
98%
|
|
Delaware Average
|
99%
|
|
Bayhealth Medical Center
|
100%
|
|
Heart attack patients given PCI within 90 minutes of arrival
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
92%
|
|
Delaware Average
|
91%
|
|
Bayhealth Medical Center
|
91%
|
|
Heart attack patients given a prescription for a statin at discharge
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
97%
|
|
Delaware Average
|
98%
|
|
Bayhealth Medical Center
|
99%
|
Pneumonia Process of Care Measures
|
Pneumonia patients assessed and given pneumococcal vaccination
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
94%
|
|
Delaware Average
|
94%
|
|
Bayhealth Medical Center
|
98%
|
|
Pneumonia patients whose initial emergency room blood culture was performed prior to the administration of the first hospital dose of antibiotics
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
96%
|
|
Delaware Average
|
95%
|
|
Bayhealth Medical Center
|
96%
|
|
Pneumonia patients given smoking cessation advice/counseling
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
98%
|
|
Delaware Average
|
100%
|
|
Bayhealth Medical Center
|
100%
|
|
Pneumonia patients given initial antibiotic(s) within 6 hours after arrival
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
96%
|
|
Delaware Average
|
94%
|
|
Bayhealth Medical Center
|
93%
|
|
Pneumonia patients given the most appropriate initial antibiotic(s)
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
94%
|
|
Delaware Average
|
92%
|
|
Bayhealth Medical Center
|
92%
|
|
Pneumonia patients assessed and given influenza vaccination
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
93%
|
|
Delaware Average
|
93%
|
|
Bayhealth Medical Center
|
95%
|
Use of Medical Imaging
|
Outpatients with low back pain who had a MRI without trying recommended treatments first, such as physical therapy. (If a number is high, it may mean the facility is doing too many unnecessary MRIs for low back pain.) |
|
U.S. Average |
32.2% |
|
Delaware Average |
25.9% |
|
Bayhealth Medical Center |
20.9% |
|
Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram. (A number that is much lower than 8% may mean there's not enough follow-up. A number much higher than 14% may mean there's too much unnecessary follow-up.) |
|
U.S. Average |
8.4% |
|
Delaware Average |
8.3% |
|
Bayhealth Medical Center |
9.6% |
|
Outpatient CT scans of the chest that were "combination" (double) scans. (The range for this measure is 0 to 1. A number very close to 1 may mean that too many patients are being given a double scan when a single scan is all they need.) |
|
U.S. Average |
0.052 |
|
Delaware Average |
0.025 |
|
Bayhealth Medical Center |
0.078 |
|
Outpatient CT scans of the abdomen that were "combination" (double) scans. (The range for this measure is 0 to 1. A number very close to 1 may mean that too many patients are being given a double scan when a single scan is all they need.) |
|
U.S. Average |
0.176 |
|
Delaware Average |
0.233 |
|
Bayhealth Average |
0.664 |
Hospital Acquired Conditions
|
Objects accidentally left in the body after surgery. |
|
U.S. Average |
0.026
per 1,000 patient discharges
|
|
Bayhealth Medical Center |
0.000
per 1,000 patient discharges |
|
Air bubbles in the bloodstream |
|
U.S. Average |
0.003
per 1,000 patient discharges |
|
Bayhealth Medical Center |
0.000
per 1,000 patient discharges |
|
Mismatched blood types |
|
U.S. Average |
0.001
per 1,000 patient discharges |
|
Bayhealth Medical Center |
0.000
per 1,000 patient discharges |
|
Severe pressure sores (bed sores) |
|
U.S. Average |
0.135
per 1,000 patient discharges |
|
Bayhealth Medical Center |
0.149
per 1,000 patient discharges |
|
Fall and injuries |
|
U.S. Average |
1.269
per 1,000 patient discharges |
|
Bayhealth Medical Center |
0.564
per 1,000 patient discharges |
|
Blood infection from a catheter in a large vein |
|
|
U.S. Average |
0.367
per 1,000 patient discharges |
|
Bayhealth Medical Center |
0.299
per 1,000 patient discharges |
|
Infection from a urinary catheter |
|
|
U.S. Average |
0.316
per 1,000 patient discharges |
|
Bayhealth Medical Center |
0.075
per 1,000 patient discharges |
|
Signs of uncontrolled blood sugar |
|
U.S. Average |
0.050
per 1,000 patient discharges |
|
Bayhealth Medical Center |
0.075
per 1,000 patient discharges |
Heart Failure Process of Care Measures
|
Heart failure patients given discharge instructions
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
90%
|
|
Delaware Average
|
93%
|
|
Bayhealth Medical Center
|
95%
|
|
Heart failure patients given an evaluation of Left Ventricular Systolic (LVS) function
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
98%
|
|
Delaware Average
|
99%
|
|
Bayhealth Medical Center
|
100%
|
|
Heart failure patients given ACE inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
95%
|
|
Delaware Average
|
95%
|
|
Bayhealth Medical Center
|
99%
|
|
Heart failure patients given smoking cessation advice/counseling
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
99%
|
|
Delaware Average
|
100%
|
|
Bayhealth Medical Center
|
99%
|
Surgical Care Improvement Process of Care Measures
|
Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
95%
|
|
Delaware Average
|
94%
|
|
Bayhealth Medical Center
|
90%
|
|
Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
95%
|
|
Delaware Average
|
93%
|
|
Bayhealth Medical Center
|
96%
|
|
Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on the beta blockers during the period just before and after their surgery
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
95%
|
|
Delaware Average
|
97%
|
|
Bayhealth Medical Center
|
93%
|
|
Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
97%
|
|
Delaware Average
|
98%
|
|
Bayhealth Medical Center
|
97%
|
|
Surgery patients who were given the right kind of antibiotic to help prevent infection
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
98%
|
|
Delaware Average
|
99%
|
|
Bayhealth Medical Center
|
99%
|
|
Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
96%
|
|
Delaware Average
|
98%
|
|
Bayhealth Medical Center
|
96%
|
|
Heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery
Data collected from 7/1/2009 – 6/30/2010
|
|
U.S. Average
|
94%
|
|
Delaware Average
|
96%
|
|
Bayhealth Medical Center
|
100%
|
|
Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electronic clippers or hair removal cream - not a razor)
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
100%
|
|
Delaware Average
|
100%
|
|
Bayhealth Medical Center
|
100%
|
|
Surgery patients whose urinary catheters were removed on the first or second day after surgery
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
92%
|
|
Delaware Average
|
94%
|
|
Bayhealth Medical Center
|
92%
|
|
Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
99%
|
|
Delaware Average
|
100%
|
|
Bayhealth Medical Center
|
98%
|
|
Surgery patients whose d doctors ordered treatments to prevent blood clots after certain types of surgeries
Data collected from 4/1/2010 – 3/31/2011
|
|
U.S. Average
|
95%
|
|
Delaware Average
|
96%
|
|
Bayhealth Medical Center
|
96%
|
|
Patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery
Data collected from 7/1/2009 – 3/31/2010
|
|
U.S. Average
|
94%
|
|
Delaware Average
|
93%
|
|
Bayhealth Medical Center
|
92%
|