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Publicly Reported Quality Measures

On this page, you will find hospital-wide publicly reported quality performance measures for Infection Prevention, Nursing CareHeart Care, Pneumonia Care, and Surgical Care Infection Prevention.

For more information about each measure and its benchmark, click on the name of the measure.

Infection Prevention:

Nationwide, 2.5 million patients develop healthcare-associated infections annually. Infections can cause additional medical problems for patients, increase the time a patient spends in the hospital, and sometimes can result in serious illness. The risk of healthcare-associated infections can be reduced by following best practices for infection control. 

Infections BIDMC Performance1
Q4 FY 13
BIDMC Goal3
Preventing Ventilator Associated Pneumonia
A higher score is better.
98% 90%
Central Line Associated Blood Stream Infections in ICUs
A lower score is better.

       0.32    

 1.21


Hand Hygiene BIDMC Performance1
Q4 FY 13
BIDMC Goal3
Hand Hygiene: Intensive Care Unit
A higher score is better
88% 90%
Hand Hygiene: Medical-Surgical
A higher score is better
60% 90%

Nursing Care:

Nursing care at BIDMC is dedicated to providing the highest quality of care and safety to our patients.  We participate in PatientCareLink as part of this commitment.  Through PatientCareLink, Massachusetts hospitals are working to reduce medical errors and promote a safe and supportive work environment, publicly report staffing plans that meet patients' needs, alleviate shortages of nurses and other caregivers, and work collaboratively with others to ensure access to safe, high-quality care for all.  BIDMC also monitors the nursing measures below for quality and safety. 

Ulcers
BIDMC Performance1
Q4 FY 13
Benchmark Comparison2 BIDMC Goal3
Pressure Ulcers - Stage II &
Above: Medical Units
A lower score is better
3.33% 1.81% 0%
Pressure Ulcers - Stage II & Above: Medical-Surgical Units
A lower score is better
4.14% 1.46% 0%

Falls
BIDMC Performance1
Q4 FY 13
Benchmark Comparison2 BIDMC Goal3
Patient Falls - Medical Units
A lower score is better
2.74 3.62 2.49
Patient Falls -Medical-Surgical Units
A lower score is better
3.10 3.68 2.05

Heart Care:

Over 1,300 patients are admitted annually to BIDMC with heart failure or a heart attack (acute myocardial infarction - AMI)  Learn more about heart care at BIDMC >>

The information below tells you how closely BIDMC has been following recommended guidelines for some measures for treatment of heart failure and heart attack (AMI). 

Appropriate and Timely Treatment
for Heart Attack
BIDMC Performance1
Q4 FY 13
Top 10%4
10/10-09/11
ACE Inhibitors and ARB's
A higher score is better
100% 100%
Administering aspirin on arrival
A higher score is better
100% 100%

Prevention of Future
Heart Attacks
BIDMC Performance1
Q4 FY 13
Top 10%4
10/10-09/11
Administering aspirin at discharge
A higher score is better
100% 100%
Administering beta blockers at discharge
A higher score is better
100% 100%

Post Discharge Outcomes BIDMC Performance1
07/09-06/12
US National Performance4
07/09-06/12
Heart Attack 30-day Mortality
A lower score is better
12.2% 15.2%
Heart Attack 30-day Readmission
A lower score is better
20.6% 18.3%

Appropriate and Timely Treatment
for Heart Failure
BIDMC Performance1
Q4 FY 13
Top 10%4
10/10-09/11
Assessment of left ventricular function
A higher score is better
100% 100%

Prevention of Future
Heart Failure
BIDMC Performance1
Q4 FY 13
Top 10%4
10/10-09/11
Prescribing ACE Inhibitors and ARBs on discharge
A higher score is better
100% 100%
Providing discharge instructions for self- management
A higher score is better
100% 100%

Post Discharge Outcomes BIDMC Performance1
07/09-06/12
US National Performance4
07/09-06/12
Heart Failure 30-day Mortality
A lower score is better
9.2% 11.7%
Heart Failure
30-day Readmission
A lower score is better
24.8% 23.0%

Pneumonia Care:

The information below tells you how closely BIDMC has been following recommended guidelines for some measures for pneumonia care.

Appropriate Treatment BIDMC Performance1
Q4 FY 13
Top 10%4
4/12-3/13
Blood cultures before first antibiotic
A higher score is better
98% 100%
Choosing appropriate antibiotics
A higher score is better
94% 100%
Outcomes BIDMC Performance1
07/09-06/12
US National Performance4
07/09-06/12
Pneumonia 30-day Mortality
A lower score is better
9.4% 11.9%
Pneumonia 30-day Readmission
A lower score is better
18.3% 19.6%

Surgical Care - Infection Prevention:

Prevention of
Post-Surgical Infections
BIDMC Performance1
Q4 FY 13
Top 10%4
4/12-3/13
Antibiotic one hour before surgery
A higher score is better.
100% 100%
Antibiotics stopped within 24 hours of surgery
A higher score is better.
100% 100%
Selecting appropriate antibiotics
A higher score is better.
99% 100%

1Source of this data is from hospital administrative databases, and reflects data reported to regulatory agencies.
2Souce of comparison data for Pressure Ulcers and Patient Falls is Massachusetts PatientCareLink.
3The Comparison for BIDMC is based on a review of a nationally recognized database of comparable institutions, or drawn from internal benchmarks that BIDMC has established, and is based upon hospital performance data reported regulatory agencies.
4The source of the comparison for these measures is Hospital Compare, Centers for Medicare & Medicaid Services. The data reported for this set of measures are drawn from a representative sample of patients rather than all surgical patients.


Last updated: January 2014

Contact Information

Silverman Institute for Health Care Quality and Safety
Beth Israel Deaconess Medical Center
330 Brookline Ave
Boston, MA 02215
617-667-1325