2019 HAI Annual Data Report

December 30, 2020 The final 2019 HAI report will be posted at a later date. The data on the following pages has been approved by all acute and critical access facilities. Alabama Hospitals 2019 CAUTI Report for Review Includes data from medical wards, surgical wards, medical/surgical wards, and adult and pediatric critical care units. Facilities without these units report data from mixed age/mixed acuity wards. Ratio of Hospital Number of Observed to Performance Volume of Number of Type Region Hospital Name Catheter Expected Compared to Hospital CAUTIs Days Infections National (SIR) Performance CAUTI State State of Alabama N/A 305 405,574 0.632 Better* CAUTI Southeast Andalusia Health Medium 0 2,099 0 Similar CAUTI North Athens Limestone Hospital Medium 3 3,370 1.671 Similar CAUTI Southwest Atmore Community Hospital Medium 0 588 N/A - CAUTI Central Baptist Medical Center East High 9 5,972 1.447 Similar CAUTI Central Baptist Medical Center South High 33 16,880 1.115 Similar CAUTI West Bibb Medical Center Medium 1 418 N/A - CAUTI Birmingham Brookwood Medical Center Medium 6 5,439 1.001 Similar CAUTI Central Bullock County Hospital Low 0 54 N/A Similar CAUTI Birmingham Children's Health System Medium 3 1,759 1.046 Similar CAUTI Southwest Choctaw General Hospital Low 0 235 N/A - CAUTI Northeast Citizens Baptist Medical Center Medium 1 1,312 N/A - CAUTI Northeast Clay County Hospital Medium 1 337 N/A - CAUTI Central Community Hospital Medium 0 502 N/A - CAUTI Northeast Coosa Valley Medical Center Medium 0 2,471 0 Similar CAUTI Central Crenshaw Community Hospital Low 2 284 N/A - CAUTI North Crestwood Medical Center Medium 1 4,925 0.291 Similar CAUTI North Cullman Regional Medical Center High 3 7,042 0.598 Similar CAUTI Southwest D.W. McMillan Memorial Hospital Medium 0 873 N/A -

Data pulled 12/28/20. SIR calculated using 2015 national baseline data. Page 1 of 6 Includes data from medical wards, surgical wards, medical/surgical wards, and adult and pediatric critical care units. Facilities without these units report data from mixed age/mixed acuity wards. Ratio of Hospital Number of Observed to Performance Volume of Number of Type Region Hospital Name Catheter Expected Compared to Hospital CAUTIs Days Infections National (SIR) Performance CAUTI Southeast Dale Medical Center Medium 0 547 N/A - CAUTI West DCH Regional Medical Center High 29 24,072 0.87 Similar CAUTI North Decatur Morgan Hospital - Decatur Campus High 4 9,105 0.509 Similar CAUTI North Decatur Morgan Hospital - Parkway Campus Medium 1 1,181 N/A - CAUTI Northeast DeKalb Regional Medical Center Medium 0 2,729 0 Similar CAUTI Central EAMC-Lanier Low 0 195 N/A - CAUTI Central East Alabama Medical Center High 1 6,918 0.17 Better CAUTI Central Elmore Community Hospital Low 0 190 N/A - CAUTI Southwest Evergreen Medical Center Low 0 126 N/A - CAUTI West Fayette Medical Center Medium 1 384 N/A - CAUTI Southeast Flowers Hospital High 10 11,205 0.96 Similar CAUTI Northeast Floyd Cherokee Medical Center Low 0 135 N/A - CAUTI Northeast Gadsden Regional Medical Center High 2 13,031 0.156 Better CAUTI Birmingham Grandview Medical Center High 30 18,004 0.99 Similar CAUTI West Greene County Hospital Low 0 24 N/A - CAUTI Southwest Grove Hill Memorial Hospital Low 1 269 N/A - CAUTI West Hale County Hospital Low 0 24 N/A - CAUTI North Helen Keller Hospital Medium 1 4,912 0.288 Similar CAUTI North Highlands Medical Center Medium 1 1,485 N/A - CAUTI West Hill Hospital of Sumter County Low 0 0 N/A -

Data pulled 12/28/20. SIR calculated using 2015 national baseline data. Page 2 of 6 Includes data from medical wards, surgical wards, medical/surgical wards, and adult and pediatric critical care units. Facilities without these units report data from mixed age/mixed acuity wards. Ratio of Hospital Number of Observed to Performance Volume of Number of Type Region Hospital Name Catheter Expected Compared to Hospital CAUTIs Days Infections National (SIR) Performance CAUTI North Huntsville Hospital High 21 25,064 0.521 Better CAUTI Central Jack Hughston Memorial Hospital Medium 1 647 N/A - CAUTI Central Jackson Hospital & Clinic High 11 11,491 1.103 Similar CAUTI Southwest Jackson Medical Center Low 0 279 N/A - CAUTI Southwest John Paul Jones Hospital Low 0 59 N/A - CAUTI Central Lake Martin Community Hospital Medium 0 346 N/A - CAUTI North Lakeland Community Hospital Medium 0 391 N/A - CAUTI North Lawrence Medical Center Low 1 327 N/A - CAUTI North Marshall Medical Center North Medium 4 2,890 2.993 Similar CAUTI North Marshall Medical Center South Medium 1 5,038 0.372 Similar CAUTI Southeast Medical Center Barbour Medium 0 833 N/A - CAUTI Southeast Medical Center Enterprise Medium 0 1,964 0 Similar CAUTI Birmingham Medical West High 7 9,269 0.756 Similar CAUTI Southeast Mizell Memorial Hospital Medium 0 928 N/A - CAUTI Southwest Mobile Infirmary Medical Center High 19 16,839 0.921 Similar CAUTI Southwest Monroe County Hospital Medium 0 568 N/A - CAUTI North North Alabama Medical Center High 2 10,175 0.224 Better CAUTI Southwest North Baldwin Infirmary Medium 1 706 N/A - CAUTI North North Mississippi Medical Center-Hamilton Low 0 130 N/A - CAUTI Northeast Northeast Alabama Regional Medical Center Medium 5 5,420 1.47 Similar

Data pulled 12/28/20. SIR calculated using 2015 national baseline data. Page 3 of 6 Includes data from medical wards, surgical wards, medical/surgical wards, and adult and pediatric critical care units. Facilities without these units report data from mixed age/mixed acuity wards. Ratio of Hospital Number of Observed to Performance Volume of Number of Type Region Hospital Name Catheter Expected Compared to Hospital CAUTIs Days Infections National (SIR) Performance CAUTI West Northport Medical Center Medium 2 3,420 0.575 Similar CAUTI West Northwest Medical Center Medium 0 621 N/A - CAUTI West Pickens County Medical Center Low 0 152 N/A - CAUTI Central Prattville Baptist Hospital Medium 2 2,157 1.828 Similar CAUTI Birmingham Princeton Baptist Medical Center High 6 14,301 0.335 Better CAUTI Southwest Providence Hospital High 0 7,955 0 Better CAUTI North Red Bay Hospital Low 0 111 N/A - CAUTI Central Regional Medical Center of Central Alabama Medium 0 818 N/A - CAUTI Northeast Riverview Regional Medical Center Medium 0 5,156 0 Better CAUTI Central Russell Medical Center Medium 0 2,465 0 Similar CAUTI North Russellville Hospital Medium 0 1,382 N/A - CAUTI Birmingham Shelby Baptist Medical Center High 3 9,486 0.357 Better CAUTI North Shoals Hospital Low 1 195 N/A - CAUTI Southwest South Baldwin Regional Medical Center Medium 1 3,681 0.267 Similar CAUTI Southeast Southeast Health High 3 6,890 0.271 Better CAUTI Southwest Springhill Medical Center Medium 3 5,269 0.792 Similar CAUTI Birmingham St. Vincent's Birmingham High 8 15,119 0.518 Better CAUTI Birmingham St. Vincent's Blount Medium 0 367 N/A - CAUTI Central St. Vincent's Chilton Low 0 281 N/A - CAUTI Birmingham St. Vincent's East High 9 11,694 0.598 Similar

Data pulled 12/28/20. SIR calculated using 2015 national baseline data. Page 4 of 6 Includes data from medical wards, surgical wards, medical/surgical wards, and adult and pediatric critical care units. Facilities without these units report data from mixed age/mixed acuity wards. Ratio of Hospital Number of Observed to Performance Volume of Number of Type Region Hospital Name Catheter Expected Compared to Hospital CAUTIs Days Infections National (SIR) Performance CAUTI Birmingham St. Vincent's St. Clair Medium 0 1,297 N/A - CAUTI Northeast Stringfellow Memorial Hospital Medium 1 1,822 N/A - CAUTI Northeast Tanner Medical Center-East Alabama Low 0 152 N/A - CAUTI Southwest Thomas Hospital High 3 6,532 0.593 Similar CAUTI Southeast Troy Regional Medical Center Medium 0 965 N/A - CAUTI Birmingham UAB Highlands Medium 4 4,704 0.843 Similar CAUTI Birmingham UAB Hospital High 36 39,653 0.438 Better CAUTI Southwest USA Children's & Women's Hospital Medium 0 458 N/A - CAUTI Southwest USA Medical Center High 5 7,959 0.323 Better CAUTI Central Vaughan Regional Medical Center Medium 0 2,414 0 Similar CAUTI Birmingham Walker Baptist Medical Center Medium 1 4,204 0.336 Similar CAUTI Southwest Washington County Hospital Low 0 262 N/A - CAUTI West Whitfield Regional Hospital Medium 0 812 N/A -

Data pulled 12/28/20. SIR calculated using 2015 national baseline data. Page 5 of 6 Includes data from medical wards, surgical wards, medical/surgical wards, and adult and pediatric critical care units. Facilities without these units report data from mixed age/mixed acuity wards. Ratio of Hospital Number of Observed to Performance Volume of Number of Type Region Hospital Name Catheter Expected Compared to Hospital CAUTIs Days Infections National (SIR) Performance CAUTI Southeast Wiregrass Medical Center Medium 0 588 N/A -

Volume of Hospital Low: Fewer than 335 Catheter Days Medium: 335 - 5,572 Catheter Days High: Greater than 5,572 Catheter Days

Hospital Performance Compared to National Performance (Based on 95% Confidence Interval) Better: Facility had significantly fewer infections than predicted based on 2015 national baseline data Similar: Facility did not have significantly more or less infections than predicted based on 2015 national baseline data Worse: Facility had significantly more infections than predicted based on 2015 national baseline data An SIR of "N/A" and national performance comparison of "-" indicates that a facility did not have enough predicted infections to draw meaningful comparisons

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Data pulled 12/28/20. SIR calculated using 2015 national baseline data. Page 6 of 6 Alabama Hospitals 2019 CLABSI Report for Review Includes data from adult, pediatric, and neonatal critical care units. Hospital Ratio of Number Number of Performance Volume of Observed to Type Region Hospital Name of Central Line Compared to Hospital Expected CLABSIs Days National Infections (SIR) Performance CLABSI State State of Alabama N/A 170 204,698 0.731 Better CLABSI Southeast Andalusia Regional Hospital Low 0 28 N/A - CLABSI North Athens Limestone Hospital Medium 1 506 N/A - CLABSI Southwest Atmore Community Hospital Medium 0 99 N/A - CLABSI Central Baptist Medical Center East Medium 7 2,488 2.179 Similar CLABSI Central Baptist Medical Center South High 11 7,870 1.071 Similar CLABSI Birmingham Brookwood Medical Center Medium 4 3,495 1.011 Similar CLABSI Birmingham Children's Health System High 20 16,565 0.813 Similar CLABSI Northeast Citizens Baptist Medical Center Medium 0 232 N/A - CLABSI Northeast Clay County Hospital Low 0 4 N/A - CLABSI Central Community Hospital Low 0 0 N/A - CLABSI Northeast Coosa Valley Medical Center Medium 0 291 N/A - CLABSI North Crestwood Medical Center Medium 1 1,018 N/A - CLABSI North Cullman Regional Medical Center Medium 0 1,141 N/A - CLABSI Southwest D.W. McMillan Memorial Hospital Low 1 78 N/A - CLABSI Southeast Dale Medical Center Medium 0 200 N/A - CLABSI West DCH Regional Medical Center High 4 10,998 0.308 Better CLABSI North Decatur Morgan Hospital - Decatur Campus Medium 3 1,976 1.75 Similar CLABSI North Decatur Morgan Hospital - Parkway Campus Low 0 24 N/A - CLABSI Northeast DeKalb Regional Medical Center Medium 0 357 N/A - CLABSI Central East Alabama Medical Center Medium 0 2,975 0 Similar CLABSI West Fayette Medical Center Low 0 10 N/A -

Data pulled 12/9/20. SIR calculated using 2015 national baseline data. Page 1 of 4 Includes data from adult, pediatric, and neonatal critical care units. Hospital Ratio of Number Number of Performance Volume of Observed to Type Region Hospital Name of Central Line Compared to Hospital Expected CLABSIs Days National Infections (SIR) Performance CLABSI Southeast Flowers Hospital Medium 1 2,380 0.484 Similar CLABSI Northeast Gadsden Regional Medical Center High 2 3,716 0.62 Similar CLABSI Birmingham Grandview Medical Center High 2 10,421 0.17 Better CLABSI North Helen Keller Hospital Medium 2 668 N/A - CLABSI North Highlands Medical Center Medium 0 251 N/A - CLABSI North Huntsville Hospital High 13 13,856 0.765 Similar CLABSI Central Jackson Hospital & Clinic High 4 5,918 0.779 Similar CLABSI North Lakeland Community Hospital Low 0 3 N/A - CLABSI North Marshall Medical Center North Medium 0 304 N/A - CLABSI North Marshall Medical Center South Medium 0 628 N/A - CLABSI Southeast Medical Center Barbour Low 0 96 N/A - CLABSI Southeast Medical Center Enterprise Medium 1 169 N/A - CLABSI Birmingham Medical West High 3 4,082 0.729 Similar CLABSI Southeast Mizell Memorial Hospital Low 0 67 N/A - CLABSI Southwest Mobile Infirmary Medical Center High 12 10,915 1.267 Similar CLABSI Southwest Monroe County Hospital Low 0 51 N/A - CLABSI North North Alabama Medical Center Medium 0 3,187 0 Similar CLABSI Southwest North Baldwin Infirmary Medium 0 111 N/A - CLABSI North North Mississippi Medical Center-Hamilton Low 0 19 N/A - CLABSI Northeast Northeast Alabama Regional Medical Center Medium 3 1,439 2.767 Similar CLABSI West Northport Medical Center Medium 3 2,380 1.023 Similar CLABSI West Northwest Medical Center Low 0 8 N/A - CLABSI Central Prattville Baptist Hospital Medium 0 179 N/A -

Data pulled 12/9/20. SIR calculated using 2015 national baseline data. Page 2 of 4 Includes data from adult, pediatric, and neonatal critical care units. Hospital Ratio of Number Number of Performance Volume of Observed to Type Region Hospital Name of Central Line Compared to Hospital Expected CLABSIs Days National Infections (SIR) Performance CLABSI Birmingham Princeton Baptist Medical Center High 3 7,345 0.405 Similar CLABSI Southwest Providence Hospital High 3 4,689 0.737 Similar CLABSI Central Regional Medical Center of Central Alabama Low 0 53 N/A - CLABSI Northeast Riverview Regional Medical Center Medium 1 1,372 0.967 Similar CLABSI Central Russell Medical Center Medium 0 120 N/A - CLABSI North Russellville Hospital Medium 0 170 N/A - CLABSI Birmingham Shelby Baptist Medical Center High 0 3,543 0 Better CLABSI North Shoals Hospital Low 0 28 N/A - CLABSI Southwest South Baldwin Regional Medical Center Medium 0 1,148 0 Similar CLABSI Southeast Southeast Health Medium 3 2,844 0.935 Similar CLABSI Southwest Springhill Medical Center High 5 5,198 1.277 Similar CLABSI Birmingham St. Vincent's Birmingham High 7 7,685 0.881 Similar CLABSI Birmingham St. Vincent's Blount Low 0 41 N/A - CLABSI Central St. Vincent's Chilton Low 0 19 N/A - CLABSI Birmingham St. Vincent's East High 5 7,441 0.596 Similar CLABSI Birmingham St. Vincent's St. Clair Medium 0 241 N/A - CLABSI Northeast Stringfellow Memorial Hospital Medium 0 350 N/A - CLABSI Southwest Thomas Hospital Medium 2 2,511 1.057 Similar CLABSI Southeast Troy Regional Medical Center Medium 0 318 N/A - CLABSI Birmingham UAB Highlands Medium 1 606 N/A - CLABSI Birmingham UAB Hospital High 21 33,950 0.487 Better CLABSI Southwest USA Children's & Women's Hospital High 15 7,524 1.139 Similar CLABSI Southwest USA Medical Center High 5 5,100 0.611 Similar

Data pulled 12/9/20. SIR calculated using 2015 national baseline data. Page 3 of 4 Includes data from adult, pediatric, and neonatal critical care units. Hospital Ratio of Number Number of Performance Volume of Observed to Type Region Hospital Name of Central Line Compared to Hospital Expected CLABSIs Days National Infections (SIR) Performance CLABSI Central Vaughan Regional Medical Center Medium 0 413 N/A - CLABSI Birmingham Walker Baptist Medical Center Medium 1 700 N/A - CLABSI West Whitfield Regional Hospital Low 0 45 N/A - CLABSI Southeast Wiregrass Medical Center Low 0 41 N/A -

Volume of Hospital Low: Fewer than 97 Central Line Days Medium: 97-3,519 Central Line Days High: Greater than 3,519 Central Line Days

Data pulled 12/9/20. SIR calculated using 2015 national baseline data. Page 4 of 4 Alabama Hospitals 2019 Colon SSI Report for Review Colon surgeries include inpatient surgical procedures only. SSI counts only include deep- and organ-level SSIs.

Number Number Ratio of Observed Hospital Performance Volume of Type Region Hospital Name Age Group of Colon of Colon to Expected Compared to Hospital SSIs Surgeries Infections (SIR) National Performance

Adult 81 5975 0.574 Better COLO STATE State of Alabama N/A Pediatric 2 150 0.77 Similar COLO Southeast Andalusia Regional Hospital Medium Adult 0 12 N/A - Adult 0 41 N/A - COLO North Athens Limestone Hospital Medium Pediatric 0 1 N/A - COLO Southwest Atmore Community Hospital Low Adult 0 6 N/A - COLO Central Baptist Medical Center East High Adult 0 190 0 Better Adult 5 150 1.327 Similar COLO Central Baptist Medical Center South High Pediatric 0 2 N/A - COLO Birmingham Brookwood Medical Center High Adult 3 176 1.009 Similar Adult 0 5 N/A - COLO Birmingham Children's Health System Medium Pediatric 2 90 1.477 Similar COLO Northeast Citizens Baptist Medical Center Low Adult 0 3 N/A - COLO Central Community Hospital Low Adult 0 2 N/A - COLO Northeast Coosa Valley Medical Center Medium Adult 0 19 N/A - COLO North Crestwood Medical Center Medium Adult 0 94 0 Similar COLO North Cullman Regional Medical Center Medium Adult 0 45 0 Similar COLO Southwest D.W. McMillan Memorial Hospital Medium Adult 1 25 N/A - COLO Southeast Dale Medical Center Medium Adult 0 10 N/A - Adult 3 277 0.359 Better COLO West DCH Regional Medical Center High Pediatric 0 2 N/A - COLO North Decatur Morgan Hospital - Decatur Campus Medium Adult 1 146 0.307 Similar COLO Northeast DeKalb Regional Medical Center Low Adult 1 8 N/A -

Data pulled 7/29/20. SIR calculated using 2015 national baseline data. Page 1 of 5 Colon surgeries include inpatient surgical procedures only. SSI counts only include deep- and organ-level SSIs.

COLO Central EAMC-Lanier Medium Adult 1 15 N/A - Adult 5 160 1.553 Similar COLO Central East Alabama Medical Center High Pediatric 0 1 N/A - COLO West Fayette Medical Center Low Adult 0 4 N/A - COLO Southeast Flowers Hospital Medium Adult 1 88 0.582 Similar Adult 0 125 0 Similar COLO Northeast Gadsden Regional Medical Center Medium Pediatric 0 1 N/A - COLO Birmingham Grandview Medical Center High Adult 2 254 0.38 Similar COLO North Helen Keller Hospital Medium Adult 0 48 N/A - COLO North Highlands Medical Center Low Adult 0 4 N/A - Adult 10 568 0.694 Similar COLO North Huntsville Hospital High Pediatric 0 23 N/A - COLO Central Jack Hughston Memorial Hospital Low Adult 0 3 N/A - COLO Central Jackson Hospital & Clinic High Adult 1 178 0.26 Similar COLO North Marshall Medical Center North Medium Adult 1 37 N/A - COLO North Marshall Medical Center South Medium Adult 0 35 N/A - COLO Southeast Medical Center Barbour Low Adult 0 4 N/A - COLO Southeast Medical Center Enterprise Medium Adult 0 26 N/A - COLO Birmingham Medical West Medium Adult 1 76 0.653 Similar COLO Southeast Mizell Memorial Hospital Low Adult 0 7 N/A - COLO Southwest Mobile Infirmary Medical Center High Adult 8 277 1.117 Similar COLO Southwest Monroe County Hospital Low Adult 0 2 N/A - Adult 2 89 1.017 Similar COLO North North Alabama Medical Center Medium Pediatric 0 1 N/A -

Data pulled 7/29/20. SIR calculated using 2015 national baseline data. Page 2 of 5 Colon surgeries include inpatient surgical procedures only. SSI counts only include deep- and organ-level SSIs.

COLO Southwest North Baldwin Infirmary Medium Adult 2 19 N/A - COLO Northeast Northeast Alabama Regional Medical Center High Adult 4 157 1.212 Similar COLO West Northport Medical Center Medium Adult 0 11 N/A - COLO West Northwest Medical Center Low Adult 0 3 N/A - COLO Birmingham Princeton Baptist Medical Center High Adult 1 180 0.26 Similar Adult 1 116 0.443 Similar COLO Southwest Providence Hospital Medium Pediatric 0 1 N/A - COLO Central Regional Medical Center of Central Alabama Low Adult 0 8 N/A - COLO Northeast Riverview Regional Medical Center Medium Adult 1 42 N/A - COLO Central Russell Medical Center Medium Adult 0 11 N/A - COLO North Russellville Hospital Medium Adult 1 16 N/A - COLO Birmingham Shelby Baptist Medical Center High Adult 0 154 0 Better COLO Southwest South Baldwin Regional Medical Center Medium Adult 0 35 N/A - Adult 3 165 0.773 Similar COLO Southeast Southeast Health High Pediatric 0 2 N/A - COLO Southwest Springhill Medical Center Medium Adult 1 123 0.445 Similar COLO Birmingham St. Vincent's Birmingham High Adult 2 381 0.262 Better COLO Central St. Vincent's Chilton Low Adult 0 1 N/A - COLO Birmingham St. Vincent's East High Adult 3 157 0.905 Similar COLO Birmingham St. Vincent's St. Clair Medium Adult 0 11 N/A - COLO Northeast Stringfellow Memorial Hospital Medium Adult 0 11 N/A - Southwest Thomas Hospital Medium Adult 1 117 0.455 Similar COLO Southeast Troy Regional Medical Center Medium Adult 0 19 N/A - COLO Birmingham UAB Highlands Low Adult 1 4 N/A -

Data pulled 7/29/20. SIR calculated using 2015 national baseline data. Page 3 of 5 Colon surgeries include inpatient surgical procedures only. SSI counts only include deep- and organ-level SSIs.

Adult 12 711 0.572 Better COLO Birmingham UAB Hospital High Pediatric 0 2 N/A - Adult 0 3 N/A - COLO Southwest USA Children's & Women's Hospital Medium Pediatric 0 23 N/A - Adult 2 248 0.201 Better COLO Southwest USA Medical Center High Pediatric 0 1 N/A - COLO Central Vaughan Regional Medical Center Medium Adult 0 17 N/A - COLO Birmingham Walker Baptist Medical Center Medium Adult 0 36 N/A - COLO West Whitfield Regional Hospital Low Adult 0 5 N/A - COLO Southeast Wiregrass Medical Center Low Adult 0 5 N/A -

Volume of Hospital Low: Fewer than 10 Total Colon Surgeries Medium: 10 - 150 Total Colon Surgeries High: Greater than 150 Total Colon Surgeries

Age Group Adult: at least 18 years old Pediatric: less than 18 years old

Hospital Performance Compared to National Performance (Based on 95% Confidence Interval of SIR) Better: Facility had significantly fewer infections than predicted based on 2015 national baseline data Similar: Facility did not have significantly more or less infections than predicted based on 2015 national baseline data Worse: Facility had significantly more infections than predicted based on 2015 national baseline data An SIR of "N/A" and national performance comparison of "-" indicates that a facility did not have enough predicted infections to draw meaningful comparisons

Data pulled 7/29/20. SIR calculated using 2015 national baseline data. Page 4 of 5 Colon surgeries include inpatient surgical procedures only. SSI counts only include deep- and organ-level SSIs.

Data pulled 7/29/20. SIR calculated using 2015 national baseline data. Page 5 of 5 Alabama Hospitals 2019 Hysterectomy SSI Report for Review Hysterectomies include inpatient abdominal hysterectomies only. SSI counts only include deep- and organ-level SSIs.

Number of Ratio of Observed Hospital Performance Volume of Age Number of Type Region Hospital Name Hysterectomy to Expected Compared to National Hospital Group Hysterectomies SSIs Infections (SIR) Performance

Adult 53 7510 1.212 Similar HYST STATE State of Alabama N/A Pediatric 0 5 N/A - HYST Southeast Andalusia Regional Hospital Low Adult 0 2 N/A - HYST North Athens Limestone Hospital Medium Adult 1 45 N/A - HYST Central Baptist Medical Center East High Adult 4 537 1.721 Similar HYST Central Baptist Medical Center South Medium Adult 3 75 N/A - HYST Birmingham Brookwood Medical Center High Adult 2 892 0.501 Similar HYST Northeast Coosa Valley Medical Center Medium Adult 0 29 N/A - HYST North Crestwood Medical Center High Adult 8 300 4.903 Worse HYST North Cullman Regional Medical Center Medium Adult 0 37 N/A - HYST Southwest D.W. McMillan Memorial Hospital Medium Adult 0 34 N/A - HYST West DCH Regional Medical Center High Adult 5 269 2.942 Worse HYST North Decatur Morgan Hospital - Decatur Campus Medium Adult 0 29 N/A - HYST Northeast DeKalb Regional Medical Center Medium Adult 0 29 N/A - Adult 1 383 0.56 Similar HYST Central East Alabama Medical Center High Pediatric 0 1 N/A - HYST Southeast Flowers Hospital High Adult 0 262 0 Similar HYST Northeast Gadsden Regional Medical Center Medium Adult 0 40 N/A - HYST Birmingham Grandview Medical Center High Adult 1 176 0.988 Similar HYST Southwest Grove Hill Memorial Hospital Low Adult 0 5 N/A - HYST North Helen Keller Hospital Medium Adult 0 42 N/A - HYST North Highlands Medical Center Medium Adult 0 16 N/A - Adult 1 786 0.204 Similar HYST North Huntsville Hospital High Pediatric 0 2 N/A - HYST Central Jackson Hospital & Clinic Medium Adult 0 75 N/A - HYST North Marshall Medical Center North Low Adult 0 1 N/A - HYST North Marshall Medical Center South Medium Adult 0 30 N/A -

Data pulled 7/29/20. SIR calculated using 2015 national baseline data. Page 1 of 3 Hysterectomies include inpatient abdominal hysterectomies only. SSI counts only include deep- and organ-level SSIs.

HYST Southeast Medical Center Barbour Low Adult 0 1 N/A - HYST Southeast Medical Center Enterprise Medium Adult 2 107 N/A - HYST Birmingham Medical West Medium Adult 0 10 N/A - HYST Southwest Mobile Infirmary Medical Center High Adult 8 233 5.974 Worse Adult 0 64 N/A - HYST North North Alabama Medical Center Medium Pediatric 0 1 N/A - HYST Southwest North Baldwin Infirmary Medium Adult 0 38 N/A - HYST Northeast Northeast Alabama Regional Medical Center Medium Adult 0 174 0 Similar HYST West Northport Medical Center Medium Adult 0 99 N/A - HYST West Northwest Medical Center Low Adult 0 4 N/A - HYST Birmingham Princeton Baptist Medical Center Medium Adult 1 45 N/A - HYST Southwest Providence Hospital Medium Adult 0 165 N/A - HYST Northeast Riverview Regional Medical Center Low Adult 0 3 N/A - HYST Central Russell Medical Center Low Adult 0 3 N/A - HYST North Russellville Hospital Low Adult 0 2 N/A - HYST Birmingham Shelby Baptist Medical Center Medium Adult 0 69 N/A - HYST Southwest South Baldwin Regional Medical Center Low Adult 0 2 N/A - Adult 0 211 0 Similar HYST Southeast Southeast Health High Pediatric 0 1 N/A - HYST Southwest Springhill Medical Center High Adult 1 316 0.633 Similar HYST Birmingham St. Vincent's Birmingham High Adult 1 433 0.389 Similar HYST Birmingham St. Vincent's East Medium Adult 1 65 N/A - HYST Birmingham St. Vincent's St. Clair Low Adult 0 2 N/A - HYST Northeast Stringfellow Memorial Hospital Low Adult 0 1 N/A - HYST Southwest Thomas Hospital High Adult 0 214 N/A - HYST Southeast Troy Regional Medical Center Medium Adult 0 7 N/A - HYST Birmingham UAB Highlands Low Adult 0 6 N/A - HYST Birmingham UAB Hospital High Adult 7 802 1.108 Similar

Data pulled 7/29/20. SIR calculated using 2015 national baseline data. Page 2 of 3 Hysterectomies include inpatient abdominal hysterectomies only. SSI counts only include deep- and organ-level SSIs.

HYST Southwest USA Children's & Women's Hospital Medium Adult 2 147 1.51 Similar HYST Southwest USA Medical Center Medium Adult 3 68 N/A - HYST Central Vaughan Regional Medical Center Medium Adult 1 40 N/A - HYST Birmingham Walker Baptist Medical Center Medium Adult 0 83 N/A - HYST Southeast Wiregrass Medical Center Low Adult 0 2 N/A -

Volume of Hospital Low: Fewer than 7 Total Hysterectomies Medium: 7 - 175 Total Hysterectomies High: Greater than 175 Total Hysterectomies

Age Group Adult: at least 18 years old Pediatric: less than 18 years old

Data pulled 7/29/20. SIR calculated using 2015 national baseline data. Page 3 of 3