2005 New Jersey Hospital Performance Report

N EW J ERSEY 2005 Hospital Performance Report

A Report on Acute Care Hospitals for RICHARD J. CODEY FRED M. JACOBS, M.D., J.D. Consumers Acting Governor Commissioner A message…

from the from the governor commissioner

Dear Friends: Dear Consumers: The people of New Jersey deserve the highest It is the Department’s goal to help patients and families quality health care available. My administration is make informed health care choices. That is why we dedicated to helping our hospitals, which admit are pleased to present the New Jersey 2005 Hospital more than a million patients each year, improve the Performance Report, which contains important information quality of care they provide. This partnership works consumers can use when making hospital care decisions. to provide the best possible health care to every This second annual report contains measures showing corner of our state. how well New Jersey hospitals performed in 2004 when treating patients with heart attack (acute myocardial A key component of our strategy is this second infarction) and pneumonia, two conditions commonly annual hospital performance report. It measures treated in hospitals nationwide. New Jersey’s hospitals to determine how often they use best practices for patients with specific By publishing this report, the Department not only aims to illnesses, and gives comparative information. empower consumers, but to also provide feedback hospitals can use on how well they are performing. We believe New Jersey’s hospitals, committed to achieving this promotes hospital accountability and efforts to improve excellence, use this data to identify areas of success the quality of patient care. Standards used in the report and improvement. I am pleased to note that the were developed by the Joint Commission on Accreditation 2004 performance was an improvement over 2003, of Healthcare Organizations and are endorsed by the and challenge our hospitals to continue this trend. National Quality Forum. I am sure they will rise to the challenge. New Jersey’s Quality Improvement Advisory Committee’s With good wishes, (QIAC) contributions to this report, and to other quality initiatives, are invaluable to our efforts. QIAC was created as a public/private partnership of leaders representing hospitals, physicians and nurses, insurers and other payers, and universities to help the Department promote the highest Richard J. Codey standards of health care in New Jersey’s hospitals. Their Acting Governor participation in this report is only a small portion of their

For additional copies of this report, please contact value to the Department. the Office of Health Care Quality Assessment, Division of Health Care Quality and Oversight, New We hope that both consumers and hospitals find this report Jersey Department of Health and Senior Services, to be a valuable resource. P.O. Box 360, Trenton, New Jersey 08625-0360; or call (800) 418-1397; or fax (609) 530-7478. There is a charge for multiple copies. This report is also available on the Department’s web site at www.state.nj.us/health/hpr. Some portions of this report rely on explanatory materials developed by the US Department of Health and Human Services Centers for Medicare and Fred M. Jacobs, M.D., J.D. Medicaid Services and the Agency for Healthcare Commissioner Research and Quality. contents

2–3 Hospital Quality and Using This Report How to use this report

4–5 Heart Attack Treatment Scores • Overall heart attack score • Aspirin on arrival • Aspirin at discharge • Beta blocker on arrival • Beta blocker at discharge • ACE inhibitor at discharge

6–7 Basic Facts About Treatment for Heart Attacks Reviews the treatment measures in this report and gives health care information

8–9 Pneumonia Treatment Scores • Overall pneumonia score • Oxygenation assessment • Pneumonia vaccination screening • Antibiotic timing

10 Basic Facts About Treatment for Pneumonia Reviews the treatment measures in this report and gives health care information

11 Hospital Quality Oversight Reviews oversight activities

12–13 Taking an Active Role in Your Health Care Reviews patient responsibilities in maintaining health including understanding treatment options

14–15 Hospital Patients…Know Your Rights Reviews patient rights in New Jersey

16 Filing Hospital Complaints How to file a complaint

17 Appendix 1 Quality Improvement Advisory Committee Membership

18 Appendix 2 Hospital Treatment Scores for heart attacks and pneumonia by geographic area

22 Appendix 3 NJ General Acute Care Hospitals ospital Quality and HUSING THIS REPORT

The New Jersey Hospital Performance Report was created to provide information on hospital quality to patients and their families as well as health care professionals. The information in this report is designed to help you choose a hospital and make other decisions about your health care. The report includes information on how hospitals treat patients who have pneumonia or a heart attack. It is important that patients with these conditions receive the correct care so that they can recover as fully as possible. Your Questions—Our Answers Why does the report focus on Research has shown that these treatments are heart attacks and pneumonia? important for patients with heart attacks or pneumonia. You can find out why these treatments are Heart disease is the leading cause of important later in this report. death in the United States. Each year over 1 million people suffer from a heart attack What do the numbers mean? or acute myocardial infarction (AMI) and almost one-fifth die from the disease. There are The report gives rates for each hospital, i.e., more than 2 million hospitalizations each year for the percentage of eligible patients who AMI and other forms of coronary heart disease. If received the correct treatment. Not every people get the correct care after an AMI, they will patient is eligible for all of the treatments. recover more fully and be less likely to have another Some may have a medical history which one. This report presents information on the makes some treatments inappropriate for them. For following important treatments in the hospital for a example, an 85% rate means that the hospital heart attack: provided the recommended care for 85% of the • Aspirin on arrival • Beta blocker at discharge eligible patients. The ultimate goal for all measures • Aspirin at discharge • ACE inhibitor at discharge is 100%, with all patients receiving the best care. The • Beta blocker on arrival report includes a summary of how a hospital treats patients for AMI and pneumonia, as well as the Pneumonia accounts for 10 million doctor visits, individual measures listed above. 500,000 hospitalizations and 45,000 deaths a year nationally. This report gives information on how Hospital scores have not been verified by external well hospitals provided the following important sources. Small differences in hospital scores treatments for pneumonia: do not mean that there are real differences in • Oxygenation assessment hospital quality. • Pneumonia vaccination screening • Antibiotic timing

2 2005 HOSPITAL PERFORMANCE REPORT Which hospitals are included? Aren’t all doctors and hospitals the same? All New Jersey general acute care hospitals are included, along with one specialty No. Hospitals differ in their specialties and hospital that treats heart disease. expertise. Some are better equipped than others to handle different types of conditions and different levels of care. Hospitals, in How can I learn more about how turn, employ doctors with different specialties, the information is collected? expertise and abilities. Hospitals also differ in how well they deliver care and keep you healthy. If you would like to learn more about how this information is collected, review the Why should I care about quality? technical report on our web site at Hospitals differ in how well they provide www.state.nj.us/health/hpr. appropriate care to patients. The quality of If doctors make decisions about the care provided by your doctor and where a patient should go for hospital may influence your health and care, why should I study your family’s health. hospital performance? Can I use this information to draw Many consumers want a doctor’s conclusions about the hospitals in recommendation on where to go for care. New Jersey? Frequently, people collect as much information The New Jersey Hospital Performance Report as possible in order to make an informed is not intended to be used alone. This report decision. This report will provide you with some is designed to provide you with important of that information. information that can help you make informed Many people choose their doctors according to decisions. It should be used in conjunction with the hospital with which they are affiliated. A doctor other information that you gather. must have privileges at a hospital in order to admit patients there. Your doctor may be able to admit to Now that I have the New Jersey several hospitals. Hospital Performance Report, what should I do with the In addition, if you are enrolled in a managed health information that I learn? care insurance plan, you can use this report to help you assess your hospital network. Managed Ask your doctor questions. Be informed. Use care insurers usually offer several choices of this report to gather more information and hospitals in an area. to make informed decisions about which hospital is most appropriate for your health care needs.

Use this report as one component of the information you consider in making decisions about hospitals.

2005 HOSPITAL PERFORMANCE REPORT 3 Heart Attack Treatment Scores This information summarizes hospital performance (rates) on treating heart attacks in 2004. The Overall Score is a composite measure of the five heart attack measures: the administration of aspirin at arrival, aspirin prescribed at discharge, the administration of beta blocker at arrival, beta blocker prescribed at discharge, and ACE inhibitor prescribed at discharge. The rate is the percent of time that a hospital gave patients the correct treatment. The hospitals are presented from the highest (best) to lowest Overall Score.

Overall Aspirin Aspirin Beta Beta ACE Hospital Name County Score Arrival Discharge Blocker Blocker Inhibitor % %%Arrival Discharge Discharge %%% Top 10% of hospitals scored equal to or higher than: 9898 99 100 99 100 100 Top 50% of hospitals scored equal to or higher than: 9494 95 93 95 93 85 Cathedral–St. James Hospital Essex100 100 NA NA NA NA NA Chilton Memorial Hospital Morris100 100 99 100 100 100 NA University Medical Center at Princeton Mercer100 100 100 98 99 100 NA Deborah Heart and Lung Center Burlington 9999 NA 100 NA 100 95 St. Peter’s University Hospital Middlesex 9999 99 100 99 100 NA Overlook Hospital Union 9999 99 99 98 100 100 Virtua-Memorial Hospital Burlington Cty. Burlington 9999 98 99 99 100 96 Clara Maass Medical Center Essex 9999 99 100 98 100 NA Virtua-West Jersey Hospital Voorhees Camden 9898 98 100 99 99 NA Robert Wood Johnson University Hospital Middlesex 9898 97 100 98 98 90 Morristown Memorial Hospital Morris 9898 99 100 99 98 93 Our Lady of Lourdes Medical Center Camden 9898 94 98 97 98 96 Community Medical Center Ocean 9898 96 98 97 100 100 South Jersey Hospital–Elmer Salem 9797 97 NA 100 96 NA Cathedral–St. Michael’s Medical Center Essex 9797 99 97 99 97 97 Irvington General Hospital Essex 9797 100 NA NA NA NA Virtua–West Jersey Hospital Berlin Camden 9797 95 97 98 100 NA Capital Health System at Fuld Mercer 9797 95 NA 100 100 NA St. Francis Medical Center Mercer 9797 98 98 100 98 83 St. Clare’s Hospital–Sussex Sussex 9797 NA NA NA NA NA AtlantiCare Regional Medical Center–Mainland Atlantic 9797 98 98 98 97 85 Hackensack University Medical Center Bergen 9797 98 98 99 97 90 Englewood Hospital and Medical Center Bergen 9797 95 100 97 99 80 Riverview Medical Center Monmouth 9797 98 96 99 90 NA Palisades Medical Center of New York Hudson 9696 99 90 98 91 NA AtlantiCare Regional Medical Center–City Atlantic 9696 92 98 97 100 NA RWJ University Hospital at Hamilton Mercer 9696 96 93 97 97 92 St. Barnabas Medical Center Essex 9696 97 96 94 96 91 Raritan Bay Medical Center–Perth Amboy Middlesex 9595 98 96 93 96 88 Mountainside Hospital Essex 9595 96 96 97 96 85 Virtua–West Jersey Hospital Marlton Burlington 9595 94 94 96 100 NA Union Hospital Union 9595 98 93 96 93 NA Cooper Hospital/University Medical Center Camden 9595 95 97 93 97 82 Underwood-Memorial Hospital Gloucester 9595 94 86 99 95 NA Kimball Medical Center Ocean 9595 95 96 95 95 NA Kennedy Mem. Hospitals UMC–Stratford Camden 9494 98 89 97 91 NA Hunterdon Medical Center Hunterdon 9494 95 100 94 93 NA Capital Health System at Mercer Mercer 9494 95 100 90 95 NA

4 2005 HOSPITAL PERFORMANCE REPORT UNTEPG O AI AT BU RAMN O ER ATTACKS FOR HEART TREATMENT ABOUT FACTS BASIC FOR PAGE TURN THE Overall Aspirin Aspirin Beta Beta ACE Hospital Name County Score Arrival Discharge Blocker Blocker Inhibitor % %%Arrival Discharge Discharge %%% St. Clare’s Hospital–Denville Morris94 94 96 92 97 89 NA St. Joseph’s Hospital and Medical Center Passaic94 94 99 92 95 93 82 Newton Memorial Hospital Sussex94 94 94 93 93 94 NA Jersey Shore University Medical Center Monmouth94 94 93 97 90 94 82 UMDNJ-University Hospital Essex94 94 96 93 96 91 97 Southern Ocean County Hospital Ocean93 93 94 91 92 93 NA Bayonne Medical Center Hudson93 93 100 83 93 92 NA Monmouth Medical Center Monmouth93 93 95 95 93 92 NA Burdette Tomlin Memorial Hospital Cape May92 92 89 94 96 97 NA RWJ University Hospital at Rahway Union92 92 94 84 95 89 NA Jersey City Medical Center Hudson92 92 99 NA 98 76 NA Lourdes Medical Center of Burlington Cty. Burlington91 91 94 NA 92 93 NA South Jersey Healthcare Reg. Medical Center * Cumberland91 91 93 89 95 88 NA Warren Hospital Warren91 91 92 88 91 93 NA Somerset Medical Center Somerset91 91 93 97 84 94 93 Pascack Valley Hospital Bergen91 91 93 90 93 91 77 Hackettstown Community Hospital Warren90 90 87 85 99 89 NA Valley Hospital Bergen90 90 89 90 90 93 79 Newark Beth Israel Medical Center Essex90 90 96 92 90 89 71 Muhlenberg Regional Medical Center Union89 89 92 89 88 89 NA William B. Kessler Memorial Hospital Atlantic89 89 93 94 90 81 NA Ocean Medical Center Ocean88 88 88 91 84 93 89 Shore Memorial Hospital Atlantic88 88 88 90 84 92 NA Kennedy Mem. Hospitals UMC–Cherry Hill Camden86 86 94 80 86 81 NA St. Joseph’s Wayne Hospital Passaic86 86 92 85 84 76 NA Meadowlands Hospital Medical Center Hudson86 86 93 NA 86 NA NA Raritan Bay Medical Center-Old Bridge Middlesex86 86 91 90 87 75 NA Trinitas Hospital Union86 86 89 74 92 82 NA Kennedy Mem. Hospitals UMC–Wash. Twp. Gloucester85 85 87 71 93 81 NA St. Mary’s Hospital (Passaic) Passaic85 85 90 NA 75 NA NA Holy Name Hospital Bergen83 83 94 63 95 65 50 Columbus Hospital Essex83 83 85 NA 82 NA NA Memorial Hospital of Salem County Salem82 82 94 59 91 64 NA JFK Medical Center (Edison) Middlesex82 82 90 72 85 72 60 Bayshore Community Hospital Monmouth82 82 94 61 84 67 NA PBI Regional Medical Center Passaic81 81 94 78 88 77 52 CentraState Medical Center Monmouth81 81 89 79 75 78 NA Greenville Hospital Hudson78 78 87 62 81 73 NA Barnert Hospital Passaic78 78 84 NA 75 NA NA Bergen Regional Medical Center Bergen77 77 NA NA NA NA NA St. Clare’s Hospital–Dover + Morris76 76 NA NA NA NA NA East Orange General Hospital Essex76 76 87 51 89 57 NA St. Mary Hospital (Hoboken) Hudson75 75 86 50 78 68 NA Christ Hospital Hudson67 67 89 38 65 44 NA

NA (Not Applicable) indicates that the hospital had a small number (less than 25) of patients for this measure and so the rate is not reported publicly. However, the patients for these measures are included in the Overall Score resulting in reportable measure. * In August 2004, South Jersey Healthcare Systems closed Bridgeton and Newcomb hospitals and opened one replacement hospital, South Jersey Healthcare Regional Medical Center. The rates reflect patients from all three facilities. + Because St. Clare’s Hospital–Dover opened midyear, the data cover only the period July through December 2004.

2005 HOSPITAL PERFORMANCE REPORT 5 asic Facts About Treatment for BHEART ATTACKS This report gives information on how well hospitals are providing care for patients with heart attacks. It is important that hospitals give the right tests and treatment to every patient at the right time. A heart attack, also called an acute myocardial infarction (AMI), can occur if the arteries supplying blood to the heart become blocked, and the blood supply is slowed or stopped. The heart muscle can’t get the oxygen and nutrients it needs. The part of the heart tissue that is affected may die. The symptoms of a heart attack can include chest pain (often described as a crushing, squeezing or burning pain in the center of the chest and may radiate to the arm or jaw), shortness of breath, dizziness, faintness, chills, sweating or nausea. Skin may feel cold or clammy, and patients may appear gray and look very ill. Sometimes there are no symptoms. The following measures included in this report show the treatments considered standard for someone who is getting hospital care for a heart attack.

Percent of Heart Attack Patients Percent of Heart Attack Who Are Given Aspirin at Arrival Patients Who Are Given Aspirin ❚ What does this information tell you? at Discharge This information shows the percent of heart ❚ What does this information tell you? attack patients who were given (or took) aspirin This information shows the percent of heart within 24 hours of arrival at the hospital. Higher attack patients who were given (or took) aspirin percentages are better. within 24 hours of discharge from the hospital. ❚ Why is this information important? Higher percentages are better. Taking an aspirin as soon as symptoms of a heart ❚ Why is this information important? attack begin may help reduce the severity of the Aspirin can help prevent blood clots from form- attack. Aspirin can help prevent blood clots from ing or help dissolve blood clots that have forming or help dissolve blood clots that have formed. Following a heart attack, continued use formed. Following a heart attack, continued use of aspirin may help reduce the risk of another of aspirin may help reduce the risk of another heart attack. heart attack. Aspirin can have side effects like stomach Aspirin can have side effects like stomach inflammation, bleeding or allergic reactions. inflammation, bleeding or allergic reactions. Talk to your doctor before using aspirin on a Talk to your doctor before using aspirin on a regular basis. regular basis.

6 2005 HOSPITAL PERFORMANCE REPORT Percent of Heart Attack Patients Percent of Heart Attack Patients Who Are Given a Beta Blocker Who Are Given an ACE Inhibitor at Arrival at Discharge ❚ What does this information tell you? ❚ What does this information tell you? This information shows the percent of heart This information shows the percent of heart attack patients who were given a beta blocker attack patients who were given an angiotensin- within 24 hours of arriving at the hospital. Higher converting enzyme (ACE) inhibitor for left percentages are better. ventricular systolic dysfunction when they were ❚ Why is this information important? discharged from the hospital. Higher percentages are better. Beta blockers are a type of medicine that is used to lower blood pressure, treat chest pain ❚ Why is this information important? (angina) and heart failure, and to help prevent a ACE inhibitors are a type of medicine used to heart attack. Beta blockers relieve the stress on treat heart attacks, heart failure, or decreased the heart by slowing the heart rate and reducing function of the left heart chamber (left the force with which the heart muscles contract ventricular systolic dysfunction). ACE inhibitors to pump blood. They also help keep blood can help reduce the risk of death from a heart vessels from constricting in the heart and attack if taken within 24 hours of the first brain, as well as the rest of the body. symptoms of a heart attack. Continued use may help prevent heart failure. Percent of Heart Attack Patients ACE inhibitors work by stopping the production Who Are Given a Beta Blocker of a hormone (angiotensin II) that can narrow at Discharge blood vessels. This helps reduce the pressure in the heart, lowering the patient’s blood pressure. ❚ What does this information tell you? This information shows the percent of heart For more information about heart health, check attack patients who were given a beta blocker www.americanheart.org, the American Heart when they were discharged from the hospital. Association’s web site, or www.medlineplus.gov for Higher percentages are better. health information from the National Library of ❚ Why is this information important? Medicine and the National Institutes of Health. Beta blockers are a type of medicine that is used to lower blood pressure, treat chest pain (angina) and heart failure, and to help prevent a heart attack. Beta blockers relieve the stress on the heart by slowing the heart rate and reducing the force with which the heart muscles contract to pump blood. They also help keep blood vessels from constricting in the heart and brain, as well as the rest of the body.

2005 HOSPITAL PERFORMANCE REPORT 7 Pneumonia Treatment Scores This information summarizes hospital performance (rates) on treating pneumonia in 2004. The Overall Score is a composite measure of the three pneumonia measures: oxygen assessment, pneumonia screening and vaccination, and antibiotic timing. The rate is the percent of time that a hospital gave patients the correct treatment. The hospitals are presented from the highest (best) to lowest Overall Score.

Overall Oxygenation Pneumonia Antibiotic Hospital Name County Score Assessment Vaccination Timing % %%%

Top 10% of hospitals scored equal to or higher than:92 100 89 87 Top 50% of hospitals scored equal to or higher than:84 100 71 77 AtlantiCare Regional Medical Center–City Atlantic 96 100 88 96 St. Clare’s Hospital-Sussex Sussex 93 100 85 90 AtlantiCare Regional Medical Center–Mainland Atlantic 93 100 81 93 Union Hospital Union92 100 92 84 Irvington General Hospital Essex 92 99 83 90 Hackensack University Medical Center Bergen92 100 86 87 Hackettstown Community Hospital Warren92 100 92 83 Chilton Memorial Hospital Morris92 99 93 83 Robert Wood Johnson University Hospital Middlesex92 100 93 82 South Jersey Hospital–Elmer Salem91 91 100 93 79 Kimball Medical Center Ocean91 91 99 92 81 RWJ University Hospital at Hamilton Mercer91 91 100 89 81 St. Peter’s University Hospital Middlesex 90 100 87 82 Newton Memorial Hospital Sussex90 100 80 85 Muhlenberg Regional Medical Center Union90 100 78 87 Warren Hospital Warren 90 100 88 80 Virtua–Memorial Hospital Burlington Cty. Burlington89 100 78 86 St. Clare’s Hospital-Dover + Morris 89 100 79 86 Clara Maass Medical Center Essex89 100 89 77 St. Mary’s Hospital (Passaic) Passaic 89 98 77 88 Virtua–West Jersey Hospital Berlin Camden89 99 72 87 Monmouth Medical Center Monmouth88 99 78 82 University Medical Center at Princeton Mercer88 100 82 79 St. Clare’s Hospital-Denville Morris 87 100 73 83 St. Mary Hospital (Hoboken) Hudson 87 99 88 75 St. Barnabas Medical Center Essex 87 99 83 74 Morristown Memorial Hospital Morris87 100 67 85 Cathedral–St. James Hospital Essex86 96 85 76 Riverview Medical Center Monmouth86 99 78 78 Hunterdon Medical Center Hunterdon86 100 73 79 Somerset Medical Center Somerset86 100 75 79 Ocean Medical Center Ocean86 100 76 76 Community Medical Center Ocean85 98 91 68 Pascack Valley Hospital Bergen85 96 79 77 Cathedral–St. Michael’s Medical Center Essex85 100 62 80 Valley Hospital Bergen85 99 77 76 Mountainside Hospital Essex85 100 76 76 Greenville Hospital Hudson84 99 67 75 RWJ University Hospital at Rahway Union84 96 58 88

8 2005 HOSPITAL PERFORMANCE REPORT UNTEPG O AI AT BU RAMN FOR PNEUMONIA TREATMENT ABOUT FACTS BASIC FOR PAGE TURN THE Overall Oxygenation Pneumonia Antibiotic Hospital Name County Score Assessment Vaccination Timing % %%% Englewood Hospital and Medical Center Bergen84 100 69 79 Underwood-Memorial Hospital Gloucester84 100 62 80 JFK Medical Center (Edison) Middlesex 84 100 73 73 Southern Ocean County Hospital Ocean83 100 69 75 Memorial Hospital of Salem County Salem83 99 64 79 St. Joseph’s Wayne Hospital Passaic 83 99 64 78 Shore Memorial Hospital Atlantic82 99 78 67 Burdette Tomlin Memorial Hospital Cape May81 81 100 45 84 Virtua–West Jersey Hospital Marlton Burlington81 81 100 41 91 Kennedy Mem. Hospitals UMC–Stratford Camden81 81 100 40 87 Cooper Hospital/University Medical Center Camden81 81 99 62 69 Barnert Hospital Passaic80 99 54 73 Bayshore Community Hospital Monmouth80 99 56 77 Holy Name Hospital Bergen80 100 62 70 William B. Kessler Memorial Hospital Atlantic79 100 45 80 Palisades Medical Center of New York Hudson79 99 72 63 Raritan Bay Medical Center–Old Bridge Middlesex79 98 58 73 Bergen Regional Medical Center Bergen79 95 70 68 Our Lady of Lourdes Medical Center Camden79 100 57 69 St. Francis Medical Center Mercer 79 100 66 66 Overlook Hospital Union79 100 57 71 Lourdes Medical Center of Burlington Cty. Burlington79 100 48 77 Jersey Shore University Medical Center Monmouth 79 99 80 57 Raritan Bay Medical Center–Perth Amboy Middlesex79 98 67 63 Capital Health System at Mercer Mercer78 100 53 65 Newark Beth Israel Medical Center Essex78 99 59 64 Virtua–West Jersey Hospital Voorhees Camden77 100 36 77 South Jersey Healthcare Regional Medical Center * Cumberland77 77 99 52 68 UMDNJ–University Hospital Essex77 99 54 57 PBI Regional Medical Center Passaic77 95 55 71 Kennedy Mem. Hospitals UMC–Wash. Twp. Gloucester77 100 42 71 Meadowlands Hospital Medical Center Hudson76 76 100 32 73 Bayonne Medical Center Hudson76 76 93 52 72 Kennedy Mem. Hospitals UMC–Cherry Hill Camden76 76 100 31 82 East Orange General Hospital Essex76 76 91 52 72 Christ Hospital Hudson76 76 97 55 61 Columbus Hospital Essex75 95 72 56 CentraState Medical Center Monmouth75 100 56 59 Capital Health System at Fuld Mercer73 100 49 58 Deborah Heart and Lung Center Burlington72 NA NA NA St. Joseph’s Hospital and Medical Center Passaic 72 99 20 65 Jersey City Medical Center Hudson71 71 100 20 59 Trinitas Hospital Union 66 93 22 62

2005 HOSPITAL PERFORMANCE REPORT 9 asic Facts About Treatment for BPNEUMONIA

This report gives information on how well hospitals are treating patients with pneumonia. It is important that hospitals give the right tests and treatment to every patient at the right time. Pneumonia is a viral or bacterial infection or inflammation that fills the lungs with fluid, lowering the oxygen level in the blood. Symptoms of pneumonia can include fever, fatigue, difficulty breathing, chills, “wet” cough (mucus may look green or bloody), and chest pain.

The following measures included in this report show the treatments considered standard for someone who is getting hospital care for pneumonia. Percent of Patients With vaccination before they were discharged Pneumonia Who Are Given an from the hospital if indicated. Higher Oxygenation Assessment percentages are better. ❚ Why is this information important? ❚ What does this information tell you? The pneumonia vaccine may help prevent or This information shows what percent of patients lower the risk of complications of pneumonia with pneumonia had the level of oxygen in their caused by bacteria. It may also help prevent body checked within 24 hours of arriving at the future infections. hospital. Higher percentages are better. ❚ Why is this information important? Percent of Patients With It is important to measure the amount of oxygen Pneumonia Who Receive in your blood to see if you need oxygen therapy. Antibiotics Within 4 Hours Pneumonia can lower the oxygen in your blood because the air spaces in your lungs fill with ❚ What does this information tell you? fluid. The oxygen you breathe does not get into This information shows the percent of patients your bloodstream. The assessment may include who received an antibiotic within 4 hours an ABG (arterial blood gas) or pulse oximetry of arrival at the hospital. Higher percentages (electrodes attached to a part of your body such are better. as a finger, earlobe, or skin fold). ❚ Why is this information important? Antibiotics are used to treat pneumonia caused Percent of Patients With by bacteria. Early treatment with antibiotics can Pneumonia Who Are Given a cure bacterial pneumonia and reduce the Screening for Pneumonia possibility of complications. Vaccination For more information about lung health, check ❚ What does this information tell you? www.lungusa.org, the American Lung Association’s This information shows the percent of patients web site, or www.medlineplus.gov for health with pneumonia who were screened for the information from the National Library of Medicine pneumonia vaccination and received the and the National Institutes of Health.

10 2005 HOSPITAL PERFORMANCE REPORT Hospital Quality Oversight In addition to this performance report, other steps are taken to promote quality in New Jersey hospitals. New Jersey Department of enforcement information may be found at Health and Senior Services www.state.nj.us/health/hcsa/hospfines/hfines. (DHSS), Division of Health htm#actions. Care Quality and Oversight DHSS also collects confidential information on serious preventable adverse events, The Department’s oversight activities are intended commonly called medical errors, and to promote the health, safety and welfare of ensures that hospitals review these events patients/residents in New Jersey health care to prevent reoccurrence. facilities. Within the Department, the Division of Health Care Quality and Oversight regulates Joint Commission on acute care facilities. DHSS issues licenses to hospitals, ambulatory care and other acute care Accreditation of Healthcare facilities. You can access the names, addresses, Organizations (JCAHO) licensure expiration dates and other information JCAHO is an independent, not-for-profit national on the facilities licensed by DHSS by visiting organization that evaluates and accredits nearly www.state.nj.us/health/hcsa/hospitalsearch/ 15,000 health care organizations. To find out if index.html. the hospital you are considering is accredited, visit JCAHO’s web site at www.jcaho.org, under In order to evaluate compliance with regulatory Quality Check®. You can also request a printed standards, the Department conducts compre- copy from the Customer Service Center at hensive facility inspections and also responds to (630) 792-5800. specific complaints. In addition to these surveys, the Department conducts inspections under contract to the U.S. Department of Health and New Jersey State Board of Human Services to evaluate facility compliance Medical Examiners, Division of with Medicare conditions of participation. Consumer Affairs, Department The hospital inspection covers access to care, of Law and Public Safety continuity and comprehensiveness of patient For specific information on licensure and care, patient rights, coordination of services, oversight of New Jersey physicians, visit infection control, safety of environment, staffing the Division of Consumer Affairs web site levels, quality assurance, pharmacy, emergency at www.NJdoctorlist.com. department services and physical plant. If a hospital does not meet state licensure or Medicare standards, the Department may cite the hospital for a deficiency, and the hospital must submit a plan of correction. The Department may also issue a monetary penalty or take some other action. A summary of

2005 HOSPITAL PERFORMANCE REPORT 11 aking an Active Role in TYOUR HEALTH CARE

Take responsibility for your health care by making decisions carefully and learning about your medical condition and treatment options.

Choose A Doctor Carefully Bring a list of all the medications you are taking if Check whether your insurer includes the physician you are entering the hospital. in its network. Include non-prescription medicines, herbal Get information about the doctor’s training from remedies and dietary supplements such as vitamins. the doctor’s office. Show the list of medicines to your doctor, surgeon, Find out if the doctor is board certified in his or her the hospital pharmacist, the hospital staff and the specialty area. nursing staff. ❚ Check whether there are any disciplinary actions If there isn’t time to make a list, bring the against the doctor. medications and keep them in their containers. ❚ Find out about the doctor’s office hours, back-up Make sure all your doctors know everything you coverage to handle emergencies, and how quickly are taking. you can obtain an appointment. Bring all your medications and supplements with you to your doctor at least once a year, even if you Manage Your Medications Safely are not being admitted to the hospital. Ask the pharmacist whether the medicine is what Inform your doctors, pharmacist and hospital your doctor prescribed. personnel about any existing drug allergies that you may have. Ask both your doctor and your pharmacist to tell ❚ you about your medication in terms you can While you are in the hospital, if a health understand. care professional administers or replaces your IV solution, ask about the purpose of the IV ❚ What is the purpose of the medicine? solution and the dosage. ❚ How am I supposed to take the medicine, and for how long? Get the Results of All Tests ❚ What side effects are likely? What do I do if they occur? and Procedures ❚ Is this medicine safe to take with other Call your doctor and ask for your results, whether medicines or dietary supplements I am taking? they are taken in the hospital or in your doctor’s office. ❚ What food, drink or activities should I avoid ❚ Don’t assume that the results are fine while taking this medicine? if you do not get them when expected Read the labels and inserts of the medication to or if your doctor neglects to make a follow-up learn about side effects and warnings. If you have call to explain them. any questions about the instructions, ask. Ask questions about the results and what they mean.

12 2005 HOSPITAL PERFORMANCE REPORT Know Your Treatment Options Ask your doctor to explain the treatment plan you will use at home before you are discharged from the Understand what your doctor is telling you about hospital. your medical condition. ❚ Learn about your medication. Learn as much as you can. Your doctor and/or your ❚ Find out when you can resume your regular library can help you find reliable information. activities. Ask your doctor to explain all of your alternative ❚ What kind of follow-up care will you require? treatments and non-surgical options, including the ❚ Will you need professional care? potential risks of each one. ❚ Will the hospital assist you in securing Consider getting a second opinion and weigh the someone to help with your care at home? possible outcomes of each of your options. ❚ What training will the hospital provide to you so If You Are Having Surgery that you can continue your treatment at home? ❚ Ask for copies of results of any medical and lab Be certain that you, your doctor, and your surgeon tests taken while in the hospital. all agree on exactly what will be done during surgery and what experiences you should expect. Take Charge Tell the surgeon, anesthesiologist and nurses about Take good care of your health by making any allergies or previous bad reactions to anesthe- regular appointments for routine check-ups and sia. Tell them about the medications that you are preventive care. currently taking. Talk with your doctor about when you need regular Discuss with your doctor what options you have health screenings. about where the surgery can take place: in the office, in a same-day surgery center, or in a hospital. Create a healthy lifestyle by eating right, exercising and getting the proper amount of sleep. When in the Hospital Be prepared in case of emergencies. Prepare a Choose a hospital that has treated many patients Living Will, a legal document that describes how with your condition or the surgery you need. you want to be treated in case you are incapacitated Patients have better results when they are treated in or near death. hospitals that have had a lot of experience treating Learn your rights and responsibilities while you are their condition. in the hospital. Consider asking all health care workers that (See Patient Rights Section on page 14.) have direct contact with you whether they have washed their hands. Handwashing prevents the spread of infections. Find out which hospital staff will be developing your care plan. ❚ Who will be leading this function? ❚ How often will they meet to discuss your needs? ❚ How often will information be communicated to you and your family?

2005 HOSPITAL PERFORMANCE REPORT 13 ospital Patients… HKNOW YOUR RIGHTS

Under New Jersey law, every New Jersey hospital patient is entitled to certain rights including at least the following:

Medical Care Transfers ❚ To receive an understandable explanation from ❚ To be transferred to another facility only if the your physician of your complete medical current hospital is unable to provide the level of condition including recommended treatment, appropriate medical care or if the transfer is expected results, risks, and reasonable medical requested by you or your next of kin or guardian. alternatives. If your physician believes that ❚ To receive from a physician an explanation in some of this information would be detrimental to advance of the reasons for transfer, including your health or beyond your ability to understand, alternatives, verification of acceptance from the the explanation must be given to your next of kin receiving facility, and assurance that the move or guardian. will not worsen your medical condition. ❚ To give informed written consent prior to the start of specified, non-emergency medical procedures Communication and Information or treatments only after your physician has ❚ To be treated with courtesy, consideration and explained—in terms you can understand—specific respect for your dignity and individuality. details about the recommended procedure or ❚ treatment, the risks, time to recover and reason- To know the names and functions of all physicians able medical alternatives. and other health care professionals directly caring for you. ❚ To be informed of the hospital’s written policies ❚ and procedures regarding life-saving methods and To expeditiously receive the services of a the use or withdrawal of life-support. translator or interpreter, if needed, to communicate with the hospital staff. ❚ To refuse medication and treatment to the extent ❚ permitted by law and to be informed of the To be informed of the names, titles, and medical consquences of refusal. duties of other health care professionals and educational institutions that participate in your ❚ To be included in experimental research only treatment. You have the right to refuse to allow when you have given informed consent to their participation. participate. ❚ To be advised in writing of the hospital’s rules ❚ To choose your own private professional nurse regarding the conduct of patients and visitors. and to contract directly for this care during your ❚ hospitalization. You can request from the hospital To receive a summary of your rights as a list of local non-profit professional nurses a patient, including the name(s) and phone association registries that refer nurses. number(s) of the hospital staff member(s) to whom to direct questions or complaints about ❚ To receive appropriate assessment and treatment possible violations of your rights. If at least 10% of for pain. the hospital’s service area speaks your native

14 2005 HOSPITAL PERFORMANCE REPORT language, you can receive a copy of the summary ❚ To have access to individual storage space for in your native language, if requested. your private use and to safeguard your property if you are unable to assume that responsibility. Medical Records ❚ To have prompt access to your medical records. If Freedom from Abuse your physician feels that this access is detrimental and Restraints to your health, your next of kin or guardian has a ❚ To be free from physical and mental abuse. right to see your records. ❚ To be free from restraints, unless they are ❚ To obtain a copy of your medical records at a authorized by a physician for a limited period of reasonable fee and within 30 days after time to protect your safety or the safety of others. submitting a written request to the hospital. Cost of Hospital Care Civil Rights ❚ To receive treatment and medical services without ❚ To receive a copy of the hospital payment rates, discrimination based on race, age, religion, an itemized bill, if requested, and explanation of national origin, sex, sexual preferences, handicap, the charges. diagnosis, ability to pay or source of payment. ❚ To appeal any charges, and receive an explanation ❚ To exercise your constitutional, civil and legal rights. of the appeals process. ❚ To obtain the hospital’s help in securing public Questions, Complaints assistance and private health care benefits to which you may be entitled. and Appeals ❚ To ask questions of or file grievances about Discharge Planning patient rights with a designated hospital staff member and to receive a response within a ❚ To be informed about any need for follow-up care reasonable period. and be assisted in obtaining the follow-up care ❚ required after your discharge from the hospital. To be provided, by the hospital, with contact information for the New Jersey Department of ❚ To receive sufficient time before discharge to Health and Senior Services unit that handles arrange for follow-up care after hospitalization. questions and complaints. ❚ To be informed by the hospital about the (See page 16 for details.) discharge appeal process. Privacy and Confidentiality ❚ To be provided with physical privacy during medical treatment and personal hygiene functions, unless you need assistance. ❚ To be assured confidentiality about your patient stay. Your medical and financial records shall not be released to anyone outside the hospital without your approval, unless you are transferred to another facility that requires the information, or release of the information is required and permitted by law.

2005 HOSPITAL PERFORMANCE REPORT 15 Filing Hospital Complaints

TO FILE A COMPLAINT ABOUT HOW A NEW JERSEY HOSPITAL… Treated you: Write to the Department of Health and Senior Services, Division of Health Care Quality and Oversight, Acute Care Survey Program; PO Box 360; Trenton, New Jersey 08625-0360. E-mail [email protected].

Handled your Write to the Department of Health and Senior Services, Division of Health Care application for Quality and Oversight, Office of Hospital Financial Reporting and Support, Charity Care: New Jersey Hospital Payment Assistance Program; PO Box 360; Trenton, New Jersey 08625-0360. Call the New Jersey Hospital Payment Assistance Program at (866) 588-5696 or (609) 530-7426.

Billed you: Write to the Department of Health and Senior Services, Division of Health Care Quality and Oversight, Office of Hospital Financial Reporting and Support; PO Box 360; Trenton, New Jersey 08625-0360. Call the Office of Hospital Financial Reporting and Support at (866) 588-5696 or (609) 530-7426. (Note: The Department has no jurisdiction over hospital rates and billing practices but provides technical assistance to consumers.)

Billed you AND you Write to the Department of Health and Senior Services, Division of Health Care are covered by a Quality and Oversight, Office of Managed Care; PO Box 360; Trenton, New Jersey Health New Jersey 08625-0360. Maintenance Call the Office of Managed Care at (888) 393-1062. Organization: Billed you AND Call the Medicare Program at (800) MEDICARE. you are enrolled Visit the Medicare Program at www.medicare.gov. in Medicare:

TO FILE A COMPLAINT ABOUT A NEW JERSEY PHYSICIAN WHO TREATED YOU IN THE HOSPITAL: ❚ Write to the Board of Medical Examiners; PO Box 183; Trenton, New Jersey 08625-0183. ❚ Visit the web site, www.njconsumeraffairs.gov/bme/bmeform.htm ❚ Call the Board of Medical Examiners at (609) 826-7100 to obtain a complaint form.

IF YOU HAVE A COMPLAINT ABOUT A NEW JERSEY NURSE WHO CARED FOR YOU IN THE HOSPITAL: ❚ Write to the New Jersey Board of Nursing; PO Box 45010; Newark, NJ 07101. ❚ Call the New Jersey Board of Nursing at (973) 504-6430.

16 2005 HOSPITAL PERFORMANCE REPORT PEDX1 APPENDIX

Appendix 1 Quality Improvement Advisory Committee (QIAC) Membership QIAC, an advisory committee for the Department of Health and Senior Services (DHSS), provided advice in the development of the report.

Pamela Allen, RPh (Co-Chair) Bernard W. Gerard, Jr Barbara Neidz Saint Barnabas Health Professionals and Liberty Health Care System Healthcare System Allied Employees Joyce G. Pontbriand Maureen Bueno, RN, PhD Michele Guhl PRONJ/The Healthcare Quality (Co-Chair) NJ Association of Health Plans Improvement Organization of NJ Robert Wood Johnson University Hospital Mary Willis Gulbronson John H. Scharf NJ Carpenters Fund Atlantic Health System Peter A. Gross, MD (Co-Chair) Hackensack University Aline Holmes Molly Sullivan Medical Center New Jersey Hospital Association Capital Health System

Andrea Aughenbaugh Suzanne Ianni Lou Ann Lamattina Uliano NJ State Nurses Association Hospital Alliance of New Jersey Consultant

Susan Bane, MD Felicia Karsos Susan Welsh Atlantic City Medical Center Saint Michael’s Medical Center Division of Medical Assistance and Health Services Douglas Bechard, MD Robin L. Keyack, RPh NJ Department of Jersey Shore University Virtua Health Human Services Medical Center David Knowlton Deborah Briggs NJ Health Care Quality Institute NJ Council of Teaching Hospitals DHSS Staff Len Leto Marilyn Dahl, Joel Cantor, ScD Division of Pension and Benefits Deputy Commissioner, Center for State Health Policy NJ Department of Treasury Division of Health Care Rutgers University Quality & Oversight Steven Linn, MD Lawrence Downs, Esq South Jersey Healthcare Regional Marcia Cook Medical Society of New Jersey Medical Center Todd Honeycutt Juana Jackson David Falk, MD Frank Lumia, MD Neetu Jain United Healthcare of NJ Deborah Heart and Lung Center Timothy Lowe Emmanuel Noggoh Kim Fox Michael Mutter Frances Prestianni Center for State Health Policy Valley Health System Sharon Sedlak Rutgers University Marcia Smiley Heng Zhu

2005 HOSPITAL PERFORMANCE REPORT 17 Appendix 2 Hospital Treatment Scores for heart attacks and pneumonia by geographic area and alphabetically Heart Attack APPENDIX 2 Overall Aspirin Aspirin Beta Beta ACE Region/County Hospital Name Score Arrival Discharge Blocker Blocker Inhibitor % %%Arrival Discharge Discharge %%% Top 10% of hospitals scored equal to or higher than: 9798 99 100 99 100 100 Top 50% of hospitals scored equal to or higher than: 9494 95 93 95 93 85 Northwest Sussex Newton Memorial Hospital 9494 94 93 93 94 NA St. Clare’s Hospital–Sussex 9797 NA NA NA NA NA Warren Hackettstown Community Hospital 9090 87 85 99 89 NA Warren Hospital 9191 92 88 91 93 NA Northeast Bergen Bergen Regional Medical Center 7777 NA NA NA NA NA Englewood Hospital and Medical Center 9797 95 100 97 99 80 Hackensack University Medical Center 9797 98 98 99 97 90 Holy Name Hospital 8383 94 63 95 65 50 Pascack Valley Hospital 9191 93 90 93 91 77 Valley Hospital 9090 89 90 90 93 79 Essex Cathedral–St. James Hospital 100100 NA NA NA NA NA Cathedral–St. Michael’s Medical Center 9797 99 97 99 97 97 Clara Maass Medical Center 9999 99 100 98 100 NA Columbus Hospital 8383 85 NA 82 NA NA East Orange General Hospital 7676 87 51 89 57 NA Irvington General Hospital 9797 100 NA NA NA NA Mountainside Hospital 9595 96 96 97 96 85 Newark Beth Israel Medical Center 9090 96 92 90 89 71 St. Barnabas Medical Center 9696 97 96 94 96 91 UMDNJ–University Hospital 9494 96 93 96 91 97 Hudson Bayonne Medical Center 9393 100 83 93 92 NA Christ Hospital 6767 89 38 65 44 NA Greenville Hospital 7878 87 62 81 73 NA Jersey City Medical Center 9292 99 NA 98 76 NA Meadowlands Hospital Medical Center 8686 93 NA 86 NA NA Palisades Medical Center of New York 9696 99 90 98 91 NA St. Mary Hospital (Hoboken) 7575 86 50 78 68 NA Morris Chilton Memorial Hospital 100100 99 100 100 100 NA Morristown Memorial Hospital 9898 99 100 99 98 93 St. Clare’s Hospital–Denville 9494 96 92 97 89 NA St. Clare’s Hospital–Dover + 7676 NA NA NA NA NA Passaic Barnert Hospital 7878 84 NA 75 NA NA PBI Regional Medical Center 8181 94 78 88 77 52 St. Joseph’s Hospital and Medical Center 9494 99 92 95 93 82 St. Joseph’s Wayne Hospital 8686 92 85 84 76 NA St. Mary’s Hospital (Passaic) 8585 90 NA 75 NA NA Union Muhlenberg Regional Medical Center 8989 92 89 88 89 NA Overlook Hospital 9999 99 99 98 100 100 RWJ University Hospital at Rahway 9292 94 84 95 89 NA Trinitas Hospital 8686 89 74 92 82 NA Union Hospital 9595 98 93 96 93 NA 18 2005 HOSPITAL PERFORMANCE REPORT PEDX2 APPENDIX Heart Attack Overall Aspirin Aspirin Beta Beta ACE Region/County Hospital Name Score Arrival Discharge Blocker Blocker Inhibitor % %%Arrival Discharge Discharge %%% Central Hunterdon Hunterdon Medical Center 9494 95 100 94 93 NA Mercer Capital Health System at Fuld 9797 95 NA 100 100 NA Capital Health System at Mercer 9494 95 100 90 95 NA RWJ University Hospital at Hamilton 9696 96 93 97 97 92 St. Francis Medical Center 9797 98 98 100 98 83 University Medical Center at Princeton 100100 100 98 99 100 NA Middlesex JFK Medical Center (Edison) 8282 90 72 85 72 60 Raritan Bay Medical Center–Old Bridge 8686 91 90 87 75 NA Raritan Bay Medical Center–Perth Amboy 9595 98 96 93 96 88 Robert Wood Johnson University Hospital 9898 97 100 98 98 90 St. Peter’s University Hospital 9999 99 100 99 100 NA Monmouth Bayshore Community Hospital 8282 94 61 84 67 NA CentraState Medical Center 8181 89 79 75 78 NA Jersey Shore University Medical Center 9494 93 97 90 94 82 Monmouth Medical Center 9393 95 95 93 92 NA Riverview Medical Center 9797 98 96 99 90 NA Ocean Community Medical Center 9898 96 98 97 100 100 Kimball Medical Center 9595 95 96 95 95 NA Ocean Medical Center 8888 88 91 84 93 89 Southern Ocean County Hospital 9393 94 91 92 93 NA Somerset Somerset Medical Center 9191 93 97 84 94 93 South Atlantic AtlantiCare Regional Medical Ctr.–City 9696 92 98 97 100 NA AtlantiCare Regional Medical Ctr.–Mainland 9797 98 98 98 97 85 Shore Memorial Hospital 8888 88 90 84 92 NA William B. Kessler Memorial Hospital 8989 93 94 90 81 NA Burlington Deborah Heart and Lung Center 9999 NA 100 NA 100 95 Lourdes Medical Center of Burlington Cty. 9191 94 NA 92 93 NA Virtua–Memorial Hospital Burlington Cty. 9999 98 99 99 100 96 Virtua–West Jersey Hospital Marlton 9595 94 94 96 100 NA Camden Cooper Hospital/University Medical Center 9595 95 97 93 97 82 Kennedy Mem. Hospitals UMC–Cherry Hill 8686 94 80 86 81 NA Kennedy Mem. Hospitals UMC–Stratford 9494 98 89 97 91 NA Our Lady of Lourdes Medical Center 9898 94 98 97 98 96 Virtua–West Jersey Hospital Berlin 9797 95 97 98 100 NA Virtua–West Jersey Hospital Voorhees 9898 98 100 99 99 NA Cape May Burdette Tomlin Memorial Hospital 9292 89 94 96 97 NA Cumberland South Jersey Healthcare Reg. Medical Ctr. * 9191 93 89 95 88 NA Gloucester Kennedy Mem. Hospitals UMC–Wash. Twp. 8585 87 71 93 81 NA Underwood-Memorial Hospital 9595 94 86 99 95 NA Salem Memorial Hospital of Salem County 8282 94 59 91 64 NA South Jersey Hospital–Elmer 9797 97 NA 100 96 NA NA (Not Applicable) indicates that the hospital had a small number (less than 25) of patients for this measure and so the rate is not reported publicly. However, the patients for these measures are included in the Overall Score resulting in reportable measure. * In August 2004, South Jersey Healthcare Systems closed Bridgeton and Newcomb hospitals and opened one replacement hospital, South Jersey Healthcare Regional Medical Center. The rates reflect patients from all three facilities. + Because St. Clare’s Hospital–Dover opened midyear, the data cover only the period July through December 2004.

2005 HOSPITAL PERFORMANCE REPORT 19 Appendix 2 Continued Pneumonia

APPENDIX 2 Overall Oxygenation Pneumonia Antibiotic Region/County Hospital Name Score Assessment Vaccination Timing % %%% Top 10% of hospitals scored equal to or higher than:92 84 100 89 87 Top 50% of hospitals scored equal to or higher than:84 100 71 77 Northwest Sussex Newton Memorial Hospital90 90 100 80 85 St. Clare’s Hospital–Sussex93 93 100 85 90 Warren Hackettstown Community Hospital92 92 100 92 83 Warren Hospital90 90 100 88 80 Northeast Bergen Bergen Regional Medical Center79 79 95 70 68 Englewood Hospital and Medical Center84 84 100 69 79 Hackensack University Medical Center92 92 100 86 87 Holy Name Hospital80 80 100 62 70 Pascack Valley Hospital85 85 96 79 77 Valley Hospital85 85 99 77 76 Essex Cathedral–St. James Hospital86 86 96 85 76 Cathedral–St. Michael’s Medical Center85 85 100 62 80 Clara Maass Medical Center89 89 100 89 77 Columbus Hospital75 75 95 72 56 East Orange General Hospital76 76 91 52 72 Irvington General Hospital92 92 99 83 90 Mountainside Hospital85 85 100 76 76 Newark Beth Israel Medical Center78 78 99 59 64 St. Barnabas Medical Center87 87 99 83 74 UMDNJ–University Hospital77 77 99 54 57 Hudson Bayonne Medical Center76 76 93 52 72 Christ Hospital76 76 97 55 61 Greenville Hospital84 84 99 67 75 Jersey City Medical Center71 71 100 20 59 Meadowlands Hospital Medical Center76 76 100 32 73 Palisades Medical Center of New York79 79 99 72 63 St. Mary Hospital (Hoboken)87 87 99 88 75 Morris Chilton Memorial Hospital92 92 99 93 83 Morristown Memorial Hospital87 87 100 67 85 St. Clare’s Hospital–Denville87 87 100 73 83 St. Clare’s Hospital–Dover +89 89 100 79 86 Passaic Barnert Hospital80 80 99 54 73 PBI Regional Medical Center77 77 95 55 71 St. Joseph’s Hospital and Medical Center72 72 99 20 65 St. Joseph’s Wayne Hospital83 83 99 64 78 St. Mary’s Hospital (Passaic)89 89 98 77 88 Union Muhlenberg Regional Medical Center90 90 100 78 87 Overlook Hospital79 79 100 57 71 RWJ University Hospital at Rahway84 84 96 58 88 Trinitas Hospital66 66 93 22 62 Union Hospital92 92 100 92 84

20 2005 HOSPITAL PERFORMANCE REPORT PEDX2 APPENDIX Pneumonia

Overall Oxygenation Pneumonia Antibiotic Region/County Hospital Name Score Assessment Vaccination Timing % %%% Central Hunterdon Hunterdon Medical Center86 86 100 73 79 Mercer Capital Health System at Fuld73 73 100 49 58 Capital Health System at Mercer78 78 100 53 65 RWJ University Hospital at Hamilton91 91 100 89 81 St. Francis Medical Center 79 79 100 66 66 University Medical Center at Princeton88 88 100 82 79 Middlesex JFK Medical Center (Edison)84 84 100 73 73 Raritan Bay Medical Center–Old Bridge79 79 98 58 73 Raritan Bay Medical Center–Perth Amboy79 79 98 67 63 Robert Wood Johnson University Hospital92 92 100 93 82 St. Peter’s University Hospital90 90 100 87 82 Monmouth Bayshore Community Hospital80 80 99 56 77 CentraState Medical Center75 75 100 56 59 Jersey Shore University Medical Center79 79 99 80 57 Monmouth Medical Center88 88 99 78 82 Riverview Medical Center86 86 99 78 78 Ocean Community Medical Center85 85 98 91 68 Kimball Medical Center91 91 99 92 81 Ocean Medical Center86 86 100 76 76 Southern Ocean County Hospital83 83 100 69 75 Somerset Somerset Medical Center86 86 100 75 79 South Atlantic AtlantiCare Regional Medical Center–City96 96 100 88 96 AtlantiCare Regional Medical Center–Mainland93 93 100 81 93 Shore Memorial Hospital82 82 99 78 67 William B. Kessler Memorial Hospital79 79 100 45 80 Burlington Deborah Heart and Lung Center72 72 NA NA NA Lourdes Medical Center of Burlington Cty.79 79 100 48 77 Virtua–Memorial Hospital Burlington Cty.89 89 100 78 86 Virtua–West Jersey Hospital Marlton81 81 100 41 91 Camden Cooper Hospital/University Medical Center81 81 99 62 69 Kennedy Mem. Hospitals UMC–Cherry Hill76 76 100 31 82 Kennedy Mem. Hospitals UMC–Stratford81 81 100 40 87 Our Lady of Lourdes Medical Center79 79 100 57 69 Virtua–West Jersey Hospital Berlin89 89 99 72 87 Virtua–West Jersey Hospital Voorhees77 77 100 36 77 Cape May Burdette Tomlin Memorial Hospital81 81 100 45 84 Cumberland South Jersey Healthcare Regional Medical Center *77 77 99 52 68 Gloucester Kennedy Mem. Hospitals UMC-Wash. Twp.77 77 100 42 71 Underwood–Memorial Hospital84 84 100 62 80 Salem Memorial Hospital of Salem County83 83 99 64 79 South Jersey Hospital–Elmer91 91 100 93 79

2005 HOSPITAL PERFORMANCE REPORT 21 Appendix 3 NJ General Acute Care Hospitals

APPENDIX 3 AtlantiCare Regional Medical Center–City Division Cathedral–St. Michael’s Medical Center 1925 Pacific Avenue 268 Dr. Martin Luther King Boulevard Atlantic City, NJ 08401 Newark, NJ 07102 (609) 344-4081 (973) 877-5000 www.atlanticare.org www.cathedralhealth.org AtlantiCare Regional Medical Center– CentraState Medical Center Mainland Division 901 West Main Street Jimmie Leeds Road Freehold, NJ 07728 Pomona, NJ 08240 (732) 431-2000 (609) 652-1000 www.centrastate.com www.atlanticare.org Chilton Memorial Hospital Barnert Hospital 97 West Parkway 680 Broadway Pompton Plains, NJ 07444 Paterson, NJ 07514 (973) 831-5000 (973) 977-6600 www.chiltonmemorial.org www.barnerthosp.com Christ Hospital Bayonne Medical Center 176 Palisade Avenue 29th Street & Avenue E Jersey City, NJ 07306 Bayonne, NJ 07002 (201) 795-8200 (201) 858-5000 www.christhospital.org www.bayonnemedicalcenter.com Clara Maass Medical Center Bayshore Community Hospital One Clara Maass Drive 727 North Beers Street Belleville, NJ 07109 Holmdel, NJ 07733 (973) 450-2000 (732) 739-5900 www.sbhcs.com/hospitals/clara_maass www.bchs.com Columbus Hospital Bergen Regional Medical Center 495 North 13th Street 230 E. Ridgewood Avenue Newark, NJ 07107 Paramus, NJ 07652 (973) 268-1400 (201) 967-4000 www.cathedralhealth.org www.bergenregional.com Community Medical Center Burdette Tomlin Memorial Hospital 99 Highway 37 West Two Stone Harbor Boulevard Toms River, NJ 08755 Cape May Court House, NJ 08210 (732) 557-8000 (609) 463-2000 www.sbhcs.com/hospitals/community_medical www.btmh.com Cooper Hospital/ Capital Health System at Fuld University Medical Center 750 Brunswick Avenue One Cooper Plaza Trenton, NJ 08638 Camden, NJ 08103 (609) 394-6000 (856) 342-2000 www.capitalhealth.org www.cooperhealth.org Capital Health System at Mercer Deborah Heart and Lung Center 446 Bellevue Avenue 200 Trenton Road Trenton, NJ 08618 Browns Mills, NJ 08015 (609) 394-4000 (609) 893-6611 www.capitalhealth.org www.deborah.org Cathedral–St. James Hospital East Orange General Hospital 155 Jefferson Street 300 Central Avenue Newark, NJ 07050 East Orange, NJ 07018 (973) 589-1300 (973) 672-8400 www.cathedralhealth.org www.evh.org Englewood Hospital and Medical Center 350 Engle Street Englewood, NJ 07631 (201) 894-3000 www.englewoodhospital.com

22 2005 HOSPITAL PERFORMANCE REPORT PEDX3 APPENDIX

Greenville Hospital Kennedy Memorial Hospitals– 1825 Kennedy Boulevard UMC Stratford Division Jersey City, NJ 07305 18 East Laurel Road (201) 547-6100 Stratford, NJ 08084 www.libertyhealth.org (856) 346-6000 Hackensack University Medical Center www.kennedyhealth.org 30 Prospect Avenue Kennedy Memorial Hospitals– Hackensack, NJ 07601 UMC Washington Twp. Division (201) 996-2000 435 Hurffville-Cross Keys Road www.humed.com Turnersville, NJ 08012 Hackettstown Community Hospital (856) 582-2500 651 Willow Grove Street www.kennedyhealth.org Hackettstown, NJ 07840 Kimball Medical Center (908) 852-5100 600 River Avenue www.hch.org Lakewood, NJ 08701 Holy Name Hospital (732) 363-1900 718 Teaneck Road www.sbhcs.com/hospitals/kimbal_medical Teaneck, NJ 07666 Lourdes Medical Center of (201) 833-3000 Burlington County www.holyname.org 218 Sunset Road Hunterdon Medical Center Willingboro, NJ 08046 2100 Wescott Drive (609) 835-2900 Flemington, NJ 08822 www.lourdesnet.org (908) 788-6100 Meadowlands Hospital Medical Center www.hunterdonhealthcare.org 55 Meadowlands Parkway Irvington General Hospital Secaucus, NJ 07096 832 Chancellor Avenue (201) 392-3100 Irvington, NJ 07111 www.libertyhealth.org (973) 399-6000 Memorial Hospital of Salem County www.sbhcs.com/hospitals/irvington_general 310 Woodstown Road Jersey City Medical Center Salem, NJ 08079 355 Grand Street (856) 935-1000 Jersey City, NJ 07302 www.mhschealth.com (201) 915-2000 Monmouth Medical Center www.libertyhealth.org 300 Second Avenue Jersey Shore University Medical Center Long Branch, NJ 07740 1945 Route 33 (732) 222-5200 Neptune, NJ 07753 www.sbhcs.com/hospitals/monmouth_medical (732) 775-5500 Morristown Memorial Hospital www.meridianhealth.com 100 Madison Avenue JFK Medical Center (Edison)/ Morristown, NJ 07962 Anthony M. Yelencsics Comm. Hosp. (973) 971-5000 65 James Street www.atlantichealth.org Edison, NJ 08818 Mountainside Hospital (732) 321-7000 Bay & Highland Avenues www.solarishs.org Montclair, NJ 07042 Kennedy Memorial Hospitals– (973) 429-6000 UMC Cherry Hill Division www.atlantichealth.org 2201 Chapel Avenue West Muhlenberg Regional Medical Center, Inc. Cherry Hill, NJ 08002 Park Ave. & Randolph Road (856) 488-6500 Plainfield, NJ 07061 www.kennedyhealth.org (908) 668-2000 www.muhlenberg.com

2005 HOSPITAL PERFORMANCE REPORT 23 Appendix 3 Continued

APPENDIX 3 Newark Beth Israel Medical Center Riverview Medical Center 201 Lyons Avenue One Riverview Plaza Newark, NJ 07112 Red Bank, NJ 07701 (973) 926-7000 (732) 741-2700 www.sbhcs.com/hospitals/newark_beth_israel www.meridianhealth.com Newton Memorial Hospital Robert Wood Johnson University Hospital 175 High Street One Robert Wood Johnson Place Newton, NJ 07860 PO Box 2601 (973) 383-2121 New Brunswick, NJ 08901 www.itsyourlife.com (732) 828-3000 Ocean Medical Center www.rwjuh.edu 425 Jack Martin Boulevard Robert Wood Johnson University Hospital at Hamilton Brick, NJ 08724 One Hamilton Health Place (732) 840-2200 Hamilton, NJ 08690 www.meridianhealth.com (609) 586-7900 Our Lady of Lourdes Medical Center www.rwjhamilton.org 1600 Haddon Avenue Robert Wood Johnson University Hospital at Rahway Camden, NJ 08103 865 Stone Street (856) 757-3500 Rahway, NJ 07065 www.lourdesnet.org (732) 381-4200 Overlook Hospital www.rwjuhr.com 99 Beauvoir Avenue Shore Memorial Hospital Summit, NJ 07902 1 East New York Avenue (908) 522-2000 Somers Point, NJ 08244 www.atlantichealth.org (609) 653-3500 Palisades Medical Center of New York www.shorememorial.org Presbyterian Healthcare System Somerset Medical Center 7600 River Road 110 Rehill Avenue N. Bergen, NJ 07047 Somerville, NJ 08876 (201) 854-5000 (908) 685-2200 www.palisadesmedical.org www.somersetmedicalcenter.com Pascack Valley Hospital South Jersey Healthcare Regional Medical Center 250 Old Hook Road 1505 West Sherman Avenue Westwood, NJ 07675 Vineland, NJ 08360 (201) 358-3000 (856) 641-8000 www.pvhospital.org www.sjhs.com PBI Regional Medical Center South Jersey Hospital–Elmer 350 Boulevard 501 West Front Street Passaic, NJ 07055 Elmer, NJ 08318 (973) 365-4300 (856) 363-1000 www.pbih.org www.sjhs.com Raritan Bay Medical Center– Southern Ocean County Hospital Old Bridge Division 1140 Route 72 West One Hospital Plaza Manahawkin, NJ 08050 Old Bridge, NJ 08857 (609) 978-8900 (732) 360-1000 www.soch.com www.rbmc.org St. Barnabas Medical Center Raritan Bay Medical Center– 94 Old Short Hills Road Perth Amboy Division Livingston, NJ 07039 530 New Brunswick Avenue (973) 322-5000 Perth Amboy, NJ 08861 www.sbhcs.com/hospitals/saint_barnabas (732) 442-3700 www.rbmc.org

24 2005 HOSPITAL PERFORMANCE REPORT PEDX3 APPENDIX

St. Clare’s Hospital–Denville Underwood-Memorial Hospital 25 Pocono Road 509 N. Broad Street Denville, NJ 07834 Woodbury, NJ 08096 (973) 625-6000 (856) 845-0100 www.saintclares.org www.umhospital.org St. Clare’s Hospital–Dover Union Hospital 400 West Blackwell Street 1000 Galloping Hill Road Dover, NJ 07801 Union, NJ 07083 (973) 989-3000 (908) 687-1900 www.saintclares.org www.sbhcs.com/hospitals/union_hospital St. Clare’s Hospital–Sussex University Medical Center at Princeton 20 Walnut Street 253 Witherspoon Street Sussex, NJ 07461 Princeton, NJ 08540 (973) 702-2600 (609) 497-4000 www.saintclares.org www.mcp.org St. Francis Medical Center Valley Hospital 601 Hamilton Avenue 223 North Van Dien Avenue Trenton, NJ 08629 Ridgewood, NJ 07450 (609) 599-5000 (201) 447-8000 www.stfrancismedical.com www.valleyhealth.com St. Joseph’s Hospital and Medical Center Virtua–Memorial Hospital of 703 Main Street Burlington County Paterson, NJ 07503 175 Madison Avenue (973) 754-2000 Mount Holly, NJ 08060 www.stjosephshealth.org (609) 267-0700 St. Joseph’s Wayne Hospital www.virtua.org 224 Hamburg Turnpike Virtua–West Jersey Hospital Berlin Wayne, NJ 07470 100 Townsend Avenue (973) 942-6900 Berlin, NJ 08009 www.sjwh.org (856) 322-3000 St. Mary Hospital (Hoboken) www.virtua.org 308 Willow Avenue Virtua–West Jersey Hospital Marlton Hoboken, NJ 07030 90 Brick Road (201) 418-1000 Marlton, NJ 08053 www.bonsecoursnj.com (856) 355-6000 St. Mary’s Hospital (Passaic) www.virtua.org 211 Pennington Avenue Virtua–West Jersey Hospital Voorhees Passaic, NJ 07055 101 Carnie Boulevard (973) 470-3000 Voorhees, NJ 08043 www.smh-passaic.com (856) 325-3000 St. Peter’s University Hospital www.virtua.org 254 Easton Avenue Warren Hospital New Brunswick, NJ 08903 185 Roseberry Street (732) 745-8600 Phillipsburg, NJ 08865 www.saintpetersuh.com (908) 859-6700 Trinitas Hospital www.warrenhospital.org 225 Williamson Street William B. Kessler Memorial Hospital Elizabeth, NJ 07207 600 S. White Horse Pike (908) 994-5000 Hammonton, NJ 08037 www.trinitashospital.com (609) 561-6700 UMDNJ–University Hospital www.kesslerhospital.org 150 Bergen Street Newark, NJ 07103 (973) 972-4300 www.theuniversityhospital.com