• Posted on 07/25/2016
  • Collection Periods
  • Report is based on information from Hospital Compare, a website created through the efforts of the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS) along with the Hospital Quality Alliance (HQA).  The HQA is a public-private collaboration established to promote reporting on hospital quality of care.
 Bayhealth Kent General Hospital
Dover, DE  19901
CMS Certification Number: 080004
     
 

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Quality Measures Linked to Payment

Value-Based Purchasing Program

Federal
Fiscal
Year		 Clinical Process of Care Domain Patient Experience of Care Domain Outcome Domain Efficiency Domain Total
Performance
Score		 National
Percentile		 Payment
Adjustment
2015 ### ### ### ### ### ### ###
2014 ### ### ### ### ### ### ###
2013 ### ### ### ### ### ### ###

Readmission Reduction Program

Federal
Fiscal
Year		 Heart Attack Heart Failure Pneumonia COPD Hip/Knee Readmissions
Adjustment
Factor		 Payment
Adjustment
Excess
Readmission
Ratio		 Cases Excess
Readmission
Ratio		 Cases Excess
Readmission
Ratio		 Cases Excess
Readmission
Ratio		 Cases Excess
Readmission
Ratio		 Cases
2016 ### ### ### ### ### ### ### ### ### ### ### ###
2015 ### ### ### ### ### ### ### ### ### ### ### ###
2014 ### ### ### ### ### ### ### ### ### ### ### ###
2013 ### ### ### ### ### ### ### ### ### ### ### ###

Hospital-Acquired Condition (HAC) Reduction Program

Federal
Fiscal
Year
Domain 1
Serious Complications
(AHRQ PSI 90 Composite Score)
Domain 2
Central Line-Associated Blood Stream Infections (CLABSI)
Catheter-Associated Urinary Tract Infections (CAUTI)
Surgical Site Infections - Colon Surgeries and Abdominal Hysterectomies (SSI)
 Total
HAC
Score		 Payment
Adjustment
From To Score From To Score CLABSI Score CAUTI Score SSI Score
2016 ### ### ### ### ### ### ### ### ### ### ###
2015 ### ### ### ### ### ### ### ### ### ### ###

Timely & Effective Care

Timely Heart Attack Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
AMI-7a. Fibrinolytic Medication Within 30 Minutes Of Arrival ### ### ### ### ###
AMI-8a. PCI Within 90 Minutes Of Arrival ### ### ### ### ###
OP-2. Fibrinolytic Therapy received within 30 minutes ### ### ### ### ###
OP-3b. Median Time to transfer patients for Acute Coronary Intervention ### ### ### ### ###
OP-4. Aspirin at Arrival ### ### ### ### ###
OP-5. Median Time to ECG ### ### ### ### ###

Effective Heart Attack Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

Effective Heart Failure Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
HF-2. Evaluation of Left Ventricular Systolic (LVS) Function ### ### ### ### ###

Effective Pneumonia Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
PN-6. Appropriate Initial Antibiotic Selection ### ### ### ### ###

Emergency Department: AMI Cardiac Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-1. Median Time to Fibrinolysis ### ### ### ### ###

Timely Surgical Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SCIP-INF-1. Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision ### ### ### ### ###
SCIP-INF-3. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time ### ### ### ### ###
SCIP-VTE-2. Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery ### ### ### ### ###

Effective Surgical Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SCIP-CARD-2. Patients on beta blocker at admission who received beta blocker during perioperative period ### ### ### ### ###
SCIP-INF-2. Prophylactic Antibiotic Selection ### ### ### ### ###
SCIP-INF-9. Urinary catheter removed within two days following surgery ### ### ### ### ###

Timely Emergency Department Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
ED-1b. Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient ### ### ### ### ###
ED-2b. Average (median) time patients spent in the emergency department, after the doctor decided to admit them as an inpatient before leaving the emergency department for their inpatient room ### ### ### ### ###
OP-18b. Average time patients spent in the emergency department before being sent home ### ### ### ### ###
OP-20. Average time patients spent in the emergency department before they were seen by a healthcare professional ### ### ### ### ###
OP-21. Average time patients who came to the emergency department with broken bones had to wait before receiving pain medication ### ### ### ### ###
OP-22. Percentage of patients who left the emergency department before being seen ### ### ### ### ###
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival ### ### ### ### ###

Preventive Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
IMM-2. Patients assessed and given influenza vaccination ### ### ### ### ###
IMM-3-OP-27-FAC-ADHPCT. Healthcare workers given influenza vaccination ### ### ### ### ###

Effective Children's Asthma Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

Timely Stroke Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
STK-1. Ischemic or hemorrhagic stroke patients who received treatment to prevent venous thromboembolism within 2 days of arrival ### ### ### ### ###
STK-4. Ischemic stroke patients who received t-PA within 3 hours of symptoms ### ### ### ### ###
STK-5. Ischemic stroke patients who received antithrombotic therapy within 2 days of arrival ### ### ### ### ###

Effective Stroke Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
STK-2. Ischemic stroke patients who received a prescription for an antithrombotic prior to discharge ### ### ### ### ###
STK-3. Ischemic stroke patients with an irregular heartbeat who received a prescription for an anticoagulant prior to discharge ### ### ### ### ###
STK-6. Ischemic stroke patients with high cholesterol who were given a prescription for a statin prior to discharge ### ### ### ### ###
STK-8. Ischemic or hemorrhagic stroke patients who received educational materials about stroke care during their stay ### ### ### ### ###
STK-10. Ischemic or hemorrhagic stroke patients who were evaluated for rehabilitation services ### ### ### ### ###

Blood Clot Prevention

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
VTE-1. Patients who received treatment to prevent blood clots within one day of admission or the day after surgery ### ### ### ### ###
VTE-2. ICU patients who received treatment to prevent blood clots within one day of admission, within one day of transfer to the ICU, or within one day following surgery ### ### ### ### ###
VTE-6. Patients who developed blood clots who did not receive preventative treatment ### ### ### ### ###

Blood Clot Treatment

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
VTE-3. Patients with blood clots who received recommended treatment with two blood thinners ### ### ### ### ###
VTE-4. Patients with blood clots who were treated with unfractionated IV heparin and had their blood checked using recommended procedures ### ### ### ### ###
VTE-5. Patients with blood clots who were discharged on blood thinners and received educational instructions at discharge ### ### ### ### ###

Pregnancy and Delivery Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary ### ### ### ### ###

Colonoscopy Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients ### ### ### ### ###
OP-30. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use ### ### ### ### ###

Patient Survey Results

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Survey question Measure Percent Measure Percent Measure Percent Star Rating
Nurses communicated well ### ### ### ### ### ### ###
Doctors communicated well ### ### ### ### ### ### ###
Help received quickly ### ### ### ### ### ### ###
Pain controlled well ### ### ### ### ### ### ###
Staff explained medicines ### ### ### ### ### ### ###
Room and bath kept clean ### ### ### ### ### ### ###
Area quiet at night ### ### ### ### ### ### ###
Given discharge instructions ### ### ### ### ### ### ###
Patient understood care ### ### ### ### ### ### ###
Overall hospital rating ### ### ### ### ### ### ###
Would recommend hospital ### ### ### ### ### ### ###
Summary Star Rating ### ### ### ### ### ### ###

Readmissions, Complications and Deaths

30-Day Risk Adjusted Mortality Rates

Measure Hospital Predicted Range National Average
Number Patients Mortality Rate from to
CABG ### ### ### ### ###
Heart Attack ### ### ### ### ###
Heart Failure ### ### ### ### ###
Pneumonia ### ### ### ### ###
COPD ### ### ### ### ###
Stroke ### ### ### ### ###

30-Day Risk Adjusted Readmission Rates

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
CABG ### ### ### ### ###
Heart Attack ### ### ### ### ###
Heart Failure ### ### ### ### ###
Pneumonia ### ### ### ### ###
COPD ### ### ### ### ###
Hip/Knee Surgery ### ### ### ### ###
Stroke ### ### ### ### ###
Hospital-wide ### ### ### ### ###

Surgical Complications

Measure Hospital Predicted Range National Average
Number Patients Rate from to
Complications for Hip/Knee Replacements ### ### ### ### ###
PSI-4. Death from serious treatable complications after surgery ### ### ### ### ###
PSI-6. Collapsed lung due to medical treatment ### ### ### ### ###
PSI-12. Serious blood clots after surgery ### ### ### ### ###
PSI-14. A wound that splits open after surgery ### ### ### ### ###
PSI-15. Accidental cuts and tears from medical treatment ### ### ### ### ###
PSI-90. Serious Complications ### ### ### ### ###

Healthcare Associated Infections

Measure Hospital Score State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) ### ###
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) ### ###
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) ### ###
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) ### ###
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections ### ###
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) ### ###

Payment and Value of Care

Use of Medical Imaging

Measure Hospital Footnotes Hospital Score National Average State Average
OP-8. MRI Lumbar Spine for Low Back Pain ### ### ### ###
OP-9. Mammography Follow-up Rates ### ### ### ###
OP-10. Abdomen CT - Use of Contrast Material ### ### ### ###
OP-11. Thorax CT - Use of Contrast Material ### ### ### ###
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery ### ### ### ###
OP-14. Outpatients with brain CT scans who got a sinus CT scan at the same time ### ### ### ###

Medicare Spending Per Patient

Measure Hospital Score National Average State Average
SPP-1. Spending per Hospital Patient with Medicare (displayed in ratio) ### ### ###

Measures of Psychiatric Facilities

Inpatient Psychiatric Facility Quality Reporting (IPFQR)

Measure Hospital Score National Average State Average
No Data are available for this hospital.