MHDO Hospital Quality Data Reports

Hospital Quality Data (Chapter 270) Reports

Hospitals must report quality metrics for Healthcare Associated Infection (HAI) measures specified by MHDO Rule Chapter 270 - Uniform Reporting System for Health Care Quality Data Sets.. The tables (below) are based on this data. They display how each Maine hospital performed on each measure during the 12 months from July 2015 through June 2016. Trend charts depict the change in statewide weighted average performance for each measure over the past five years.

The facilities are categorized by Maine Hospital Association Peer Groups to allow comparison between hospitals of similar size. Acute care Prospective Payment System (PPS) hospitals appear in Peer Groups A (largest) through D. Peer Group E comprises the smaller, mostly rural Critical Access Hospitals (CAH) and the New England Rehabilitation Hospital is assigned to Peer Group G. (Note: Maine's four psychiatric hospitals (Group F) were not required to report data for the HAI and NSI measures and the Togus VA Hospital is exempt from Chapter 270.)

Healthcare Associated Infection process measures for the period July 2015 to June 2016

The table below displays rates of hospital documented compliance with three sets of best practices for preventing Healthcare Acquired Infections (HAIs). The description of each measure are below. For all three measures, higher scores are better. All performance rates at 95% or better are highlighted in blue.

  • HAI-3: Documented compliance with all five evidence-based interventions for patients with intravascular central catheters (central line bundle compliance) in intensive care units
  • HAI-4: Documented compliance with the four insertion related, evidence-based interventions for patients with intravascular central catheters (central line bundle compliance) placed perioperatively in pre-operative areas, operating rooms, and recovery areas
  • HAI-5: Percent documented compliance with all five evidence-based interventions for patients with mechanical ventilation in intensive care units;

You may download the Excel version of the HAI process measures report.

HAI performance measures 2016

The table below displays hospital infection or LabID event rates for four outcomes measures described below. For all four measures, lower rates are better.

  • HAI-1: The number of central line catheter associated blood stream infections per 1,000 central line days in intensive care units, medical units, surgical units, and medical/surgical units (hospitals having no units in any of those categories report data from their mixed acuity units instead);
  • HAI-2: The number of catheter related blood stream infections among neonatal intensive care unit patients per 1,000 central line catheter or umbilical days;
  • MRSA: Hospital-onset Methicillin-resistant Staphylococcus aureus LabID events
  • C.diff.: Hospital-onset Clostridium difficile LabID events

You may download the Excel version of the HAI-1, HAI-2, MRSA and C.diff. report below.

HAI 1 and 2, MRSA and Cdiff measures for July 2015 throu June 2016

Nursing Sensitive Indicators for the period CY2017

The table below displays performance rates for three patient outcomes found to be associated with nurse staffing levels and nurse staffing plans. Descriptions of each measure can be found below. All three indicators measure avoidable outcomes; therefore, lower rates are better.

  • NSPC-1: The percentage of inpatients who have a hospital-acquired Stage II or greater pressure ulcer on one of the quarterly, oneday surveys of all patients in selected hospital units
  • NSPC-2: The number of patient falls per 1,000 patient days
  • NSPC-3: The number of patient falls with injury per 1,000 patient days

Hospital Peer Groups are designated by the Maine Hospital Association (MHA), based on bed size, revenue, critical access designation (CAH) and specialty.

  • Peer Group A: Larger acute care hospitals
  • Peer Group B: Medium-size acute care hospitals
  • Peer Group C: Smaller acute care hospitals
  • Peer Group D: Critical Access Hospitals (CAH) with up to 25 beds
  • Peer Group F: Rehabilitation hospitals

You may download the Excel version of the CY2017 NSI report.

NSI measures for CY2017

Nursing Sensitive Indicators for the period July 2015 to June 2016

The table below displays performance rates for three patient outcomes found to be associated with nurse staffing levels and nurse staffing plans. Descriptions of each measure can be found below. All three indicators measure avoidable outcomes; therefore, lower rates are better.

  • NSPC-1: The percentage of inpatients who have a hospital-acquired Stage II or greater pressure ulcer on one of the quarterly, oneday surveys of all patients in selected hospital units
  • NSPC-2: The number of patient falls per 1,000 patient days
  • NSPC-3: The number of patient falls with injury per 1,000 patient days

You may download the Excel version of the NSI report covering July 2015 - June 2016.

NSI measures for SFY2017