MHA/ONL PatientCareLink

Nursing-Sensitive Measure Report

Statistical Appendix

January 2020

January 2020

Statistical Appendix Contents

 Analysis of the Statistical Significance of Hospital Measure Rates

 Acute Care Hospitals Bed-size Group Category Listing

 Post-Acute Care Hospital Listing

 Acute Care Hospitals

o NSC-2 Pressure Ulcer Prevalence . Acute Care Hospital Bed-size Group Measure Data Graphs o NSC-3 Patient Falls . Acute Care Hospital Bed-size Group Measure Data Graphs o NSC-4 Falls with Injury . Acute Care Hospital Bed-size Group Measure Data Graphs

 Post-Acute Care Hospitals

o NSC-2 Pressure Ulcer Prevalence . Rehabilitation Hospitals Group Measure Data Graphs . Long-term Acute Care Hospitals Group Measure Data Graphs o NSC-3 Patient Falls . Rehabilitation Hospitals Group Measure Data Graphs . Long-term Acute Care Hospitals Group Measure Data Graphs o NSC-4 Falls with Injury . Rehabilitation Hospitals Group Measure Data Graphs . Long-term Acute Care Hospitals Group Measure Data Graphs

January 2020

Analysis of the Statistical Significance of Hospital Measure Rates

Because the measure rates for the hospitals are for a specific period of time, and because there is variability in performance over time because of chance and other factors, there is a degree of uncertainty about the extent to which a hospital’s measure rate may reflect its true underlying performance. Without taking this uncertainty into account, we cannot conclude that a hospital with a measure rate that is higher or lower than the group rate is truly performing at a worse or better rate than the group.

Statisticians use confidence intervals to account for this uncertainty. A confidence interval is a numeric range around the estimate represented by the hospital’s measure rate, calculated to provide a specified level of confidence that the interval includes the true underlying performance of the hospital. The confidence level chosen for this analysis, 95% confidence, means that, in repeated collection and analysis of similar data, 95% of the resulting confidence intervals will include the true rate. The use and interpretation of confidence intervals in the nursing-sensitive measures is illustrated below. For any hospital (A, B, C, or D), the measure rate represented by the square is accompanied by a confidence interval (horizontal line). When a hospital’s confidence interval does not intersect the group interval, represented by the vertical lines (hospitals A and D in the illustration), we can say that the difference between the hospital rate and the group rate is statistically significant and likely represents a true difference in performance. When the hospital’s interval completely crosses the group interval (hospitals B and C in the illustration), the difference is not statistically significant. (When a hospital’s interval extends only a small distance into the group interval, the difference may be statistically significant and additional calculation is required.)

The confidence level of 95% applies to the confidence interval for each individual hospital. In a group of 20 hospitals, one would expect, on average, that one confidence interval does not actually include the hospital’s true rate. Hospitals’ confidence intervals will vary in width because, among other factors, the measure rate is based on more or fewer observations (i.e., patient days).

Abt Associates Inc. advised MHA on the analytic approach and performed the statistical analysis.

January 2020 Hospitals will be found within the section for their bed-size group. Hospitals are listed alphabetically within bed-size groups below. Not all hospitals will have data for each unit-type. The data graphs are presented in order of hospital-bed size group, low to high. Acute Care Hospitals Less than 100 Beds 200 - 299 Beds Athol Hospital Baystate Franklin Medical Center Baystate Noble Hospital Good Samaritan Medical Center Baystate Wing Hospital Holy Family Hospital at Methuen Beth Israel Deaconess Hospital - Milton Beth Israel Deaconess Hospital - Needham Newton-Wellesley Hospital Fairview Hospital North Shore Medical Center - Salem Hospital Northeast Health System - Beverly Hospital Eye & Ear Nashoba Valley Medical Center Northeast Health System - Addison Gilbert Hospital Signature Healthcare Southcoast Hospitals Group - Tobey Hospital UMass Memorial - Marlborough Hospital 300 - 399 Beds 100 - 199 Beds Lahey Hospital & Medical Center Anna Jaques Hospital Beth Israel Deaconess Hospital - Plymouth Mercy Medical Center Brigham and Women's - Faulkner Hospital Cambridge Health Alliance - Cambridge Southcoast Hospitals Group - Charlton Memorial Cambridge Health Alliance - Everett Southcoast Hospitals Group - St. Luke's Hospital St. Elizabeth's Medical Center Cooley Dickinson Hospital Melrose Wakefield Hospital 500 or More Beds Harrington Memorial Hospital Baystate Medical Center HealthAlliance-Clinton Hospitals Beth Israel Deaconess Medical Center Heywood Hospital Medical Center Holy Family Hospital at Haverhill Brigham and Women's Hospital Massachusetts General Hospital Lawrence General Hospital UMass Memorial Medical Center MetroWest Medical Center - Framingham Campus MetroWest Medical Center - Leonard Morse Campus Milford Regional Medical Center Morton Hospital & Medical Center New England Baptist Hospital North Shore Medical Center - Union Hospital Saint Anne's Hospital Sturdy Memorial Hospital

January 2020 Hospitals will be found within the section for their hospital type. Hospitals are listed alphabetically within hospital type below. Not all hospitals will have data for each unit-type. Post Acute hospital data graphs follow the acute care hospital data graphs in this document. Post Acute Hospitals

Rehabilitation Hospitals Bronson Rehabilitation Center at Baystate Noble Hospital Encompass Health Rehabilitation of Braintree Encompass Health Rehabilitation of New England Encompass Health Rehabilitation of Western MA Fairlawn Rehabilitation Hospital Southeast Rehabilitation Hospital at Southcoast Hospitals Group - Charlton Hospital Spaulding Rehabilitation Hospital Boston Spaulding Rehabilitation Hospital Cape Cod The Center for Rehabilitation at Berkshire Medical Center Weldon Rehabilitation Hospital at Mercy Medical Center

Long-Term Acute Care Hospitals Hebrew Rehabilitation Center New England Sinai Hospital Spaulding Hospital for Continuing Medical Care Cambridge

January 2020

Acute Care Hospitals

January 2020

NSC-2 Pressure Ulcer Prevalence

June 2018* September 2018 December 2018* March 2019

* Optional studies

January 2020 Adult Critical Care Units, Less than 100 beds

Falmouth Hospital

Beth Israel Deaconess Hospital - Needham

Baystate Wing Hospital

Nashoba Valley Medical Center

Baystate Franklin Medical Center

Baystate Noble Hospital

Northeast Health System - Addison Gilbert Hospital

Southcoast Health - Tobey Hospital

Beth Israel Deaconess Hospital - Milton

Fairview Hospital

Marlborough Hospital

0 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Critical Care Units, 100-199 beds

Emerson Hospital

MetroWest Medical Center - Framingham Campus

Sturdy Memorial Hospital

Brigham & Women’s Faulkner Hospital

Milford Regional Medical Center

HealthAlliance -Clinton Hospital

Anna Jaques Hospital

Holyoke Medical Center

New England Baptist Hospital

Saint Anne's Hospital

North Shore Medical Center (NSMC) - Union Hospital

MetroWest Medical Center - Leonard Morse Campus

Heywood Hospital

Morton Hospital and Medical Center

Holy Family Hospital at Haverhill

Harrington Memorial Hospital

Beth Israel Deaconess Hospital-Plymouth

Cambridge Health Alliance - Cambridge

Melrose Wakefield Hospital

Cambridge Health Alliance - Everett

Carney Hospital

Lawrence General Hospital

Cooley Dickinson Health Care 0 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Critical Care Units, 200-299 beds

Cape Cod Hospital

Good Samaritan Medical Center

Northeast Health System - Beverly Hospital

Berkshire Medical Center

Holy Family Hospital at Methuen

Mount Auburn Hospital

Saint Vincent Hospital

North Shore Medical Center (NSMC) - Salem Hospital

Newton-Wellesley Hospital

Signature Healthcare Brockton Hospital

Winchester Hospital

Norwood Hospital

0 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Critical Care Units, 300-399 beds

St. Elizabeth's Medical Center

Lowell General Hospital

South Shore Hospital

Southcoast Health - St. Luke's Hospital

Lahey Hospital & Medical Center

Southcoast Health - Charlton Memorial Hospital

Mercy Medical Center

Tufts Medical Center

0 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Critical Care Units, More than 500 beds

UMass Memorial Medical Center

Massachusetts General Hospital

Brigham and Women's Hospital

Baystate Medical Center

Boston Medical Center

Beth Israel Deaconess Medical Center

0 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Step-Down Units, Less than 100 beds

Baystate Noble Hospital

Massachusetts Eye and Ear

0 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Step-Down Units, 100-199 beds

Holyoke Medical Center

MetroWest Medical Center - Framingham Campus

Milford Regional Medical Center

Cooley Dickinson Health Care

0 0.00% 5.00% 10.00% 15.00% 20.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Step-Down Units, 200-299 beds

Signature Healthcare Brockton Hospital

Northeast Health System - Beverly Hospital

Mount Auburn Hospital

Cape Cod Hospital

Saint Vincent Hospital

Berkshire Medical Center

0 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Step-Down Units, 300-399 beds

St. Elizabeth's Medical Center

Tufts Medical Center

Southcoast Health - Charlton Memorial Hospital

Mercy Medical Center

Southcoast Health - St. Luke's Hospital

Lowell General Hospital

0 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Step-Down Units, More than 500 beds

UMass Memorial Medical Center

Baystate Medical Center

Boston Medical Center

Beth Israel Deaconess Medical Center

0 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Medical Units, Less than 100 beds

Northeast Health System - Addison Gilbert Hospital

0 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Medical Units, 100-199 beds

Brigham & Women’s Faulkner Hospital

MetroWest Medical Center - Framingham Campus

Melrose Wakefield Hospital

Milford Regional Medical Center

Lawrence General Hospital

0 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Medical Units, 200-299 beds

Northeast Health System - Beverly Hospital

Saint Vincent Hospital

Good Samaritan Medical Center

Holy Family Hospital at Methuen

Winchester Hospital

North Shore Medical Center (NSMC) - Salem Hospital

Norwood Hospital

Newton-Wellesley Hospital

0 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% 10.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Medical Units, 300-399 beds

Tufts Medical Center

St. Elizabeth's Medical Center

Southcoast Health - St. Luke's Hospital

Southcoast Health - Charlton Memorial Hospital

South Shore Hospital

0 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% 4.00% 4.50% 5.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Medical Units, More than 500 beds

Boston Medical Center

Baystate Medical Center

Massachusetts General Hospital

UMass Memorial Medical Center

Brigham and Women's Hospital

Beth Israel Deaconess Medical Center

0 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% 4.00% 4.50% 5.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Surgical Units, Less than 100 beds

Southcoast Health - Tobey Hospital

Falmouth Hospital

0 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Surgical Units, 100-199 beds

Brigham & Women’s Faulkner Hospital

Saint Anne's Hospital

Melrose Wakefield Hospital

Cooley Dickinson Health Care

New England Baptist Hospital

0 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Surgical Units, 200-299 beds

Northeast Health System - Beverly Hospital

Mount Auburn Hospital

North Shore Medical Center (NSMC) - Salem Hospital

Winchester Hospital

Holy Family Hospital at Methuen

Newton-Wellesley Hospital

Saint Vincent Hospital

0 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Surgical Units, 300-399 beds

Southcoast Health - St. Luke's Hospital

Southcoast Health - Charlton Memorial Hospital

Tufts Medical Center

South Shore Hospital

0 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Surgical Units, More than 500 beds

Baystate Medical Center

Massachusetts General Hospital

Brigham and Women's Hospital

UMass Memorial Medical Center

Boston Medical Center

0 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% 10.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Medical-Surgical Units, Less than 100 beds

Falmouth Hospital

Beth Israel Deaconess Hospital - Needham

Baystate Franklin Medical Center

Baystate Noble Hospital

Nashoba Valley Medical Center

Massachusetts Eye and Ear

Fairview Hospital

Athol Hospital

Baystate Wing Hospital

Marlborough Hospital

Beth Israel Deaconess Hospital - Milton

Southcoast Health - Tobey Hospital

0 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Medical-Surgical Units, 100-199 beds

Sturdy Memorial Hospital

Saint Anne's Hospital

MetroWest Medical Center - Framingham Campus

Melrose Wakefield Hospital

HealthAlliance -Clinton Hospital

Emerson Hospital

Heywood Hospital

Brigham & Women’s Faulkner Hospital

Morton Hospital and Medical Center

New England Baptist Hospital

MetroWest Medical Center - Leonard Morse Campus

Holyoke Medical Center

North Shore Medical Center (NSMC) - Union Hospital

Milford Regional Medical Center

Holy Family Hospital at Haverhill

Anna Jaques Hospital

Carney Hospital

Cambridge Health Alliance - Cambridge

Cooley Dickinson Health Care

Beth Israel Deaconess Hospital-Plymouth

Cambridge Health Alliance - Everett

Harrington Memorial Hospital

Lawrence General Hospital 0 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Medical-Surgical Units, 200-299 beds

Good Samaritan Medical Center

North Shore Medical Center (NSMC) - Salem Hospital

Norwood Hospital

Northeast Health System - Beverly Hospital

Holy Family Hospital at Methuen

Winchester Hospital

Signature Healthcare Brockton Hospital

Mount Auburn Hospital

Cape Cod Hospital

Berkshire Medical Center

Saint Vincent Hospital

0 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Medical-Surgical Units, 300-399 beds

St. Elizabeth's Medical Center

Lahey Hospital & Medical Center

Mercy Medical Center

Lowell General Hospital

Southcoast Health - Charlton Memorial Hospital

South Shore Hospital

Southcoast Health - St. Luke's Hospital

0 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% Percent of Patients with Hospital Acquired Pressure Ulcers Adult Medical-Surgical Units, More than 500 beds

Boston Medical Center

Baystate Medical Center

Massachusetts General Hospital

Brigham and Women's Hospital

UMass Memorial Medical Center

Beth Israel Deaconess Medical Center

0 0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50% 4.00% Percent of Patients with Hospital Acquired Pressure Ulcers

NSC-3 Patient Falls

Apr 2018 – Mar 2019

January 2020 Adult Critical Care Units, Less than 100 beds

Falmouth Hospital

Beth Israel Deaconess Hospital - Needham

Baystate Franklin Medical Center

Baystate Noble Hospital

Marlborough Hospital

Baystate Wing Hospital

Beth Israel Deaconess Hospital - Milton

Northeast Health System - Addison Gilbert Hospital

Nashoba Valley Medical Center

Southcoast Health - Tobey Hospital

Fairview Hospital

0 0.00 2.00 4.00 6.00 8.00 10.00 12.00 Patient Falls per 1000 Patient Days Adult Critical Care Units, 100-199 beds

Morton Hospital and Medical Center

HealthAlliance -Clinton Hospital

Cambridge Health Alliance - Everett

Harrington Memorial Hospital

Brigham & Women’s Faulkner Hospital

MetroWest Medical Center - Leonard Morse Campus

Holy Family Hospital at Haverhill

Cooley Dickinson Health Care

Lawrence General Hospital

Beth Israel Deaconess Hospital-Plymouth

Sturdy Memorial Hospital

Milford Regional Medical Center

Melrose Wakefield Hospital

Anna Jaques Hospital

Emerson Hospital

Carney Hospital

Cambridge Health Alliance - Cambridge

Heywood Hospital

MetroWest Medical Center - Framingham Campus

Saint Anne's Hospital

New England Baptist Hospital

Holyoke Medical Center 0 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Patient Falls per 1000 Patient Days Adult Critical Care Units, 200-299 beds

Northeast Health System - Beverly Hospital

Berkshire Medical Center

Cape Cod Hospital

Newton-Wellesley Hospital

Signature Healthcare Brockton Hospital

Saint Vincent Hospital

Mount Auburn Hospital

Norwood Hospital

Good Samaritan Medical Center

North Shore Medical Center (NSMC) - Salem Hospital

Holy Family Hospital at Methuen

Winchester Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 Patient Falls per 1000 Patient Days Adult Critical Care Units, 300-399 beds

Lowell General Hospital

Mercy Medical Center

Tufts Medical Center

Lahey Hospital & Medical Center

St. Elizabeth's Medical Center

South Shore Hospital

Southcoast Health - Charlton Memorial Hospital

Southcoast Health - St. Luke's Hospital

0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 Patient Falls per 1000 Patient Days Adult Critical Care Units, More than 500 beds

Brigham and Women's Hospital

Baystate Medical Center

Massachusetts General Hospital

Boston Medical Center

Beth Israel Deaconess Medical Center

UMass Memorial Medical Center

0 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 Patient Falls per 1000 Patient Days Adult Step-Down Units, Less than 100 beds

Massachusetts Eye and Ear

Baystate Noble Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 Patient Falls per 1000 Patient Days Adult Step-Down Units, 100-199 beds

Milford Regional Medical Center

Cooley Dickinson Health Care

Holyoke Medical Center

MetroWest Medical Center - Framingham Campus

0 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Patient Falls per 1000 Patient Days Adult Step-Down Units, 200-299 beds

Cape Cod Hospital

Saint Vincent Hospital

Signature Healthcare Brockton Hospital

Berkshire Medical Center

Mount Auburn Hospital

Northeast Health System - Beverly Hospital

0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 Patient Falls per 1000 Patient Days Adult Step-Down Units, 300-399 beds

Lowell General Hospital

St. Elizabeth's Medical Center

Mercy Medical Center

Tufts Medical Center

Southcoast Health - St. Luke's Hospital

Southcoast Health - Charlton Memorial Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 Patient Falls per 1000 Patient Days Adult Step-Down Units, More than 500 beds

Baystate Medical Center

Boston Medical Center

Beth Israel Deaconess Medical Center

UMass Memorial Medical Center

0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Patient Falls per 1000 Patient Days Adult Medical Units, Less than 100 beds

Northeast Health System - Addison Gilbert Hospital

0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 Patient Falls per 1000 Patient Days Adult Medical Units, 100-199 beds

Melrose Wakefield Hospital

Milford Regional Medical Center

Brigham & Women’s Faulkner Hospital

Lawrence General Hospital

MetroWest Medical Center - Framingham Campus

0 0.00 1.00 2.00 3.00 4.00 5.00 Patient Falls per 1000 Patient Days Adult Medical Units, 200-299 beds

Norwood Hospital

Winchester Hospital

Saint Vincent Hospital

Newton-Wellesley Hospital

Good Samaritan Medical Center

North Shore Medical Center (NSMC) - Salem Hospital

Holy Family Hospital at Methuen

Northeast Health System - Beverly Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 Patient Falls per 1000 Patient Days Adult Medical Units, 300-399 beds

Southcoast Health - St. Luke's Hospital

South Shore Hospital

Tufts Medical Center

Southcoast Health - Charlton Memorial Hospital

St. Elizabeth's Medical Center

0 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Patient Falls per 1000 Patient Days Adult Medical Units, More than 500 beds

Baystate Medical Center

Brigham and Women's Hospital

Boston Medical Center

Massachusetts General Hospital

UMass Memorial Medical Center

Beth Israel Deaconess Medical Center

0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Patient Falls per 1000 Patient Days Adult Surgical Units, Less than 100 beds

Southcoast Health - Tobey Hospital

Falmouth Hospital

0 0.00 0.50 1.00 1.50 2.00 Patient Falls per 1000 Patient Days Adult Surgical Units, 100-199 beds

New England Baptist Hospital

Cooley Dickinson Health Care

Melrose Wakefield Hospital

Brigham & Women’s Faulkner Hospital

Saint Anne's Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 6.00 Patient Falls per 1000 Patient Days Adult Surgical Units, 200-299 beds

Winchester Hospital

Northeast Health System - Beverly Hospital

Holy Family Hospital at Methuen

Saint Vincent Hospital

Newton-Wellesley Hospital

North Shore Medical Center (NSMC) - Salem Hospital

Mount Auburn Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 Patient Falls per 1000 Patient Days Adult Surgical Units, 300-399 beds

South Shore Hospital

Tufts Medical Center

Southcoast Health - Charlton Memorial Hospital

Southcoast Health - St. Luke's Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 Patient Falls per 1000 Patient Days Adult Surgical Units, More than 500 beds

Boston Medical Center

Massachusetts General Hospital

Baystate Medical Center

Brigham and Women's Hospital

UMass Memorial Medical Center

0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Patient Falls per 1000 Patient Days Adult Medical-Surgical Units, Less than 100 beds

Massachusetts Eye and Ear

Beth Israel Deaconess Hospital - Needham

Baystate Franklin Medical Center

Falmouth Hospital

Beth Israel Deaconess Hospital - Milton

Baystate Noble Hospital

Fairview Hospital

Athol Hospital

Baystate Wing Hospital

Marlborough Hospital

Nashoba Valley Medical Center

Southcoast Health - Tobey Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Patient Falls per 1000 Patient Days Adult Medical-Surgical Units, 100-199 beds

Holyoke Medical Center

New England Baptist Hospital

Milford Regional Medical Center

Cooley Dickinson Health Care

MetroWest Medical Center - Leonard Morse Campus

Sturdy Memorial Hospital

North Shore Medical Center (NSMC) - Union Hospital

MetroWest Medical Center - Framingham Campus

Brigham & Women’s Faulkner Hospital

Anna Jaques Hospital

Melrose Wakefield Hospital

Lawrence General Hospital

Beth Israel Deaconess Hospital-Plymouth

Morton Hospital and Medical Center

Emerson Hospital

Harrington Memorial Hospital

HealthAlliance -Clinton Hospital

Cambridge Health Alliance - Cambridge

Cambridge Health Alliance - Everett

Saint Anne's Hospital

Holy Family Hospital at Haverhill

Heywood Hospital

Carney Hospital 0 0.00 1.00 2.00 3.00 4.00 5.00 6.00 Patient Falls per 1000 Patient Days Adult Medical-Surgical Units, 200-299 beds

Winchester Hospital

Northeast Health System - Beverly Hospital

Cape Cod Hospital

Norwood Hospital

Signature Healthcare Brockton Hospital

North Shore Medical Center (NSMC) - Salem Hospital

Berkshire Medical Center

Mount Auburn Hospital

Holy Family Hospital at Methuen

Good Samaritan Medical Center

Saint Vincent Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 Patient Falls per 1000 Patient Days Adult Medical-Surgical Units, 300-399 beds

Lahey Hospital & Medical Center

St. Elizabeth's Medical Center

Mercy Medical Center

South Shore Hospital

Southcoast Health - St. Luke's Hospital

Lowell General Hospital

0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Patient Falls per 1000 Patient Days Adult Medical-Surgical Units, More than 500 beds

Boston Medical Center

Baystate Medical Center

UMass Memorial Medical Center

Brigham and Women's Hospital

Beth Israel Deaconess Medical Center

Massachusetts General Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 Patient Falls per 1000 Patient Days

NSC-4 Falls with Injury

Apr 2018 – Mar 2019

January 2020 Adult Critical Care Units, Less than 100 beds

Falmouth Hospital

Marlborough Hospital

Beth Israel Deaconess Hospital - Milton

Southcoast Health - Tobey Hospital

Beth Israel Deaconess Hospital - Needham

Baystate Wing Hospital

Nashoba Valley Medical Center

Baystate Franklin Medical Center

Northeast Health System - Addison Gilbert Hospital

Baystate Noble Hospital

Fairview Hospital

0 0.00 2.00 4.00 6.00 8.00 10.00 Falls with Injury per 1000 Patient-Days Adult Critical Care Units, 100-199 beds

Beth Israel Deaconess Hospital-Plymouth

HealthAlliance -Clinton Hospital

Sturdy Memorial Hospital

MetroWest Medical Center - Framingham Campus

Emerson Hospital

Carney Hospital

Melrose Wakefield Hospital

Anna Jaques Hospital

Morton Hospital and Medical Center

Cambridge Health Alliance - Everett

Harrington Memorial Hospital

Brigham & Women’s Faulkner Hospital

MetroWest Medical Center - Leonard Morse Campus

Cambridge Health Alliance - Cambridge

Heywood Hospital

Holy Family Hospital at Haverhill

New England Baptist Hospital

Saint Anne's Hospital

Cooley Dickinson Health Care

Lawrence General Hospital

Holyoke Medical Center

Milford Regional Medical Center 0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 Falls with Injury per 1000 Patient-Days Adult Critical Care Units, 200-299 beds

Cape Cod Hospital

Saint Vincent Hospital

Signature Healthcare Brockton Hospital

Mount Auburn Hospital

Northeast Health System - Beverly Hospital

Berkshire Medical Center

Newton-Wellesley Hospital

Norwood Hospital

Good Samaritan Medical Center

Holy Family Hospital at Methuen

North Shore Medical Center (NSMC) - Salem Hospital

Winchester Hospital

0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 Falls with Injury per 1000 Patient-Days Adult Critical Care Units, 300-399 beds

Lahey Hospital & Medical Center

Tufts Medical Center

St. Elizabeth's Medical Center

South Shore Hospital

Southcoast Health - St. Luke's Hospital

Southcoast Health - Charlton Memorial Hospital

Lowell General Hospital

Mercy Medical Center

0 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 Falls with Injury per 1000 Patient-Days Adult Critical Care Units, More than 500 beds

Massachusetts General Hospital

Beth Israel Deaconess Medical Center

Brigham and Women's Hospital

Baystate Medical Center

UMass Memorial Medical Center

Boston Medical Center

0 0.00 0.10 0.20 0.30 0.40 0.50 0.60 Falls with Injury per 1000 Patient-Days Adult Step-Down Units, Less than 100 beds

Baystate Noble Hospital

Massachusetts Eye and Ear

0 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 Falls with Injury per 1000 Patient-Days Adult Step-Down Units, 100-199 beds

Milford Regional Medical Center

Cooley Dickinson Health Care

MetroWest Medical Center - Framingham Campus

Holyoke Medical Center

0 0.00 0.50 1.00 1.50 2.00 2.50 Falls with Injury per 1000 Patient-Days Adult Step-Down Units, 200-299 beds

Signature Healthcare Brockton Hospital

Northeast Health System - Beverly Hospital

Saint Vincent Hospital

Cape Cod Hospital

Berkshire Medical Center

Mount Auburn Hospital

0 0.00 0.50 1.00 1.50 2.00 Falls with Injury per 1000 Patient-Days Adult Step-Down Units, 300-399 beds

Lowell General Hospital

Tufts Medical Center

St. Elizabeth's Medical Center

Mercy Medical Center

Southcoast Health - St. Luke's Hospital

Southcoast Health - Charlton Memorial Hospital

0 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 Falls with Injury per 1000 Patient-Days Adult Step-Down Units, More than 500 beds

Beth Israel Deaconess Medical Center

Baystate Medical Center

Boston Medical Center

UMass Memorial Medical Center

0 0.00 0.50 1.00 1.50 2.00 Falls with Injury per 1000 Patient-Days Adult Medical Units, Less than 100 beds

Northeast Health System - Addison Gilbert Hospital

0 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 Falls with Injury per 1000 Patient-Days Adult Medical Units, 100-199 beds

Melrose Wakefield Hospital

MetroWest Medical Center - Framingham Campus

Lawrence General Hospital

Brigham & Women’s Faulkner Hospital

Milford Regional Medical Center

0 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 Falls with Injury per 1000 Patient-Days Adult Medical Units, 200-299 beds

Northeast Health System - Beverly Hospital

Norwood Hospital

Saint Vincent Hospital

North Shore Medical Center (NSMC) - Salem Hospital

Good Samaritan Medical Center

Winchester Hospital

Holy Family Hospital at Methuen

Newton-Wellesley Hospital

0 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 Falls with Injury per 1000 Patient-Days Adult Medical Units, 300-399 beds

South Shore Hospital

Tufts Medical Center

Southcoast Health - St. Luke's Hospital

St. Elizabeth's Medical Center

Southcoast Health - Charlton Memorial Hospital

0 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 Falls with Injury per 1000 Patient-Days Adult Medical Units, More than 500 beds

Beth Israel Deaconess Medical Center

Baystate Medical Center

Boston Medical Center

Massachusetts General Hospital

Brigham and Women's Hospital

UMass Memorial Medical Center

0 0.00 0.20 0.40 0.60 0.80 1.00 Falls with Injury per 1000 Patient-Days Adult Surgical Units, Less than 100 beds

Southcoast Health - Tobey Hospital

Falmouth Hospital

0 0.00 0.20 0.40 0.60 0.80 1.00 1.20 Falls with Injury per 1000 Patient-Days Adult Surgical Units, 100-199 beds

Melrose Wakefield Hospital

Cooley Dickinson Health Care

New England Baptist Hospital

Saint Anne's Hospital

Brigham & Women’s Faulkner Hospital

0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 Falls with Injury per 1000 Patient-Days Adult Surgical Units, 200-299 beds

Saint Vincent Hospital

Holy Family Hospital at Methuen

Northeast Health System - Beverly Hospital

Winchester Hospital

Newton-Wellesley Hospital

Mount Auburn Hospital

North Shore Medical Center (NSMC) - Salem Hospital

0 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 Falls with Injury per 1000 Patient-Days Adult Surgical Units, 300-399 beds

Southcoast Health - Charlton Memorial Hospital

Southcoast Health - St. Luke's Hospital

South Shore Hospital

Tufts Medical Center

0 0.00 0.20 0.40 0.60 0.80 1.00 1.20 Falls with Injury per 1000 Patient-Days Adult Surgical Units, More than 500 beds

Boston Medical Center

Massachusetts General Hospital

Baystate Medical Center

Brigham and Women's Hospital

UMass Memorial Medical Center

0 0.00 0.20 0.40 0.60 0.80 1.00 Falls with Injury per 1000 Patient-Days Adult Medical-Surgical Units, Less than 100 beds

Fairview Hospital

Baystate Franklin Medical Center

Beth Israel Deaconess Hospital - Milton

Beth Israel Deaconess Hospital - Needham

Massachusetts Eye and Ear

Baystate Noble Hospital

Athol Hospital

Baystate Wing Hospital

Nashoba Valley Medical Center

Falmouth Hospital

Marlborough Hospital

Southcoast Health - Tobey Hospital

0 0.00 0.50 1.00 1.50 2.00 Falls with Injury per 1000 Patient-Days Adult Medical-Surgical Units, 100-199 beds

North Shore Medical Center (NSMC) - Union Hospital

Anna Jaques Hospital

MetroWest Medical Center - Leonard Morse Campus

Cooley Dickinson Health Care

Holyoke Medical Center

Melrose Wakefield Hospital

Cambridge Health Alliance - Cambridge

Milford Regional Medical Center

Beth Israel Deaconess Hospital-Plymouth

Morton Hospital and Medical Center

Sturdy Memorial Hospital

Emerson Hospital

New England Baptist Hospital

MetroWest Medical Center - Framingham Campus

Harrington Memorial Hospital

Brigham & Women’s Faulkner Hospital

Cambridge Health Alliance - Everett

Carney Hospital

Saint Anne's Hospital

HealthAlliance -Clinton Hospital

Lawrence General Hospital

Holy Family Hospital at Haverhill

Heywood Hospital 0 0.00 0.50 1.00 1.50 2.00 2.50 Falls with Injury per 1000 Patient-Days Adult Medical-Surgical Units, 200-299 beds

Winchester Hospital

Signature Healthcare Brockton Hospital

Northeast Health System - Beverly Hospital

Cape Cod Hospital

Norwood Hospital

Holy Family Hospital at Methuen

Saint Vincent Hospital

North Shore Medical Center (NSMC) - Salem Hospital

Good Samaritan Medical Center

Berkshire Medical Center

Mount Auburn Hospital

0 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 Falls with Injury per 1000 Patient-Days Adult Medical-Surgical Units, 300-399 beds

St. Elizabeth's Medical Center

Lahey Hospital & Medical Center

Mercy Medical Center

South Shore Hospital

Southcoast Health - St. Luke's Hospital

Lowell General Hospital

0 0.00 0.50 1.00 1.50 2.00 Falls with Injury per 1000 Patient-Days Adult Medical-Surgical Units, More than 500 beds

Boston Medical Center

Baystate Medical Center

Brigham and Women's Hospital

Beth Israel Deaconess Medical Center

UMass Memorial Medical Center

Massachusetts General Hospital

0 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 Falls with Injury per 1000 Patient-Days

Post-Acute Care Hospitals

January 2020

NSC-2 Pressure Ulcer Prevalence

June 2018* September 2018 December 2018* March 2019

* Optional studies

January 2020 Rehabilitation Hospitals, Rehabilitation Unit

Encompass Health Rehabilitation Hospital of Braintree

Encompass Health Rehabilitation Hospital of Western MA

Southcoast Health - Charlton Memorial Hospital

Berkshire Medical Center

Baystate Noble Hospital

Encompass Health Rehabilitation Hospital of New England

Fairlawn Rehabilitation Hospital

Spaulding Rehabilitation Hospital Cape Cod

Mercy Medical Center

Spaulding Rehabilitation Hospital Boston

0 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% Percent of Patients with Hospital Acquired Pressure Ulcers Long-Term Acute Care Hospital, Long-Term Care Unit

Hebrew Rehabilitation Center

0 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% Percent of Patients with Hospital Acquired Pressure Ulcers Long-Term Acute Care Hospital, Medical Unit

Tewksbury Hospital

New England Sinai Hospital

Spaulding Hospital for Continuing Medical Care Cambridge

0 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% Percent of Patients with Hospital Acquired Pressure Ulcers

NSC-3 Patient Falls

Apr 2018 – Mar 2019

January 2020 Rehabilitation Hospitals, Rehabilitation Unit

Spaulding Rehabilitation Hospital Cape Cod

Spaulding Rehabilitation Hospital Boston

Mercy Medical Center

Berkshire Medical Center

Baystate Noble Hospital

Encompass Health Rehabilitation Hospital of Western MA

Southcoast Health - Charlton Memorial Hospital

Fairlawn Rehabilitation Hospital

Encompass Health Rehabilitation Hospital of New England

Encompass Health Rehabilitation Hospital of Braintree

0 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 Patient Falls per 1000 Patient Days Long-Term Acute Care Hospital, Long-Term Care Unit

Hebrew Rehabilitation Center

0 0.00 1.00 2.00 3.00 4.00 5.00 Patient Falls per 1000 Patient Days Long-Term Acute Care Hospital, Medical Unit

New England Sinai Hospital

Spaulding Hospital for Continuing Medical Care Cambridge

Tewksbury Hospital

0 0.00 1.00 2.00 3.00 4.00 5.00 Patient Falls per 1000 Patient Days

NSC-4 Falls with Injury

Apr 2018 – Mar 2019

January 2020 Rehabilitation Hospitals, Rehabilitation Unit

Berkshire Medical Center

Encompass Health Rehabilitation Hospital of Braintree

Encompass Health Rehabilitation Hospital of Western MA

Spaulding Rehabilitation Hospital Boston

Baystate Noble Hospital

Spaulding Rehabilitation Hospital Cape Cod

Mercy Medical Center

Encompass Health Rehabilitation Hospital of New England

Fairlawn Rehabilitation Hospital

Southcoast Health - Charlton Memorial Hospital

0 0 0.5 1 1.5 2 Falls with Injury per 1000 Patient-Days Long-Term Acute Care Hospital, Long-Term Care Unit

Hebrew Rehabilitation Center

0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Falls with Injury per 1000 Patient-Days Long-Term Acute Care Hospital, Medical Unit

New England Sinai Hospital

Tewksbury Hospital

Spaulding Hospital for Continuing Medical Care Cambridge

0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Falls with Injury per 1000 Patient-Days