Orgid Hospital Name Hospital System Hospital System

OrgID Hospital Name Hospital System Hospital System & Name 10482 Baystate Medical Center Baystate Health Baystate Medical Center 11303 UMass Memorial Medical Center UMass Memorial Health Care UMass Memorial Health Care - UMass Memorial Medical Center 11558 Tufts Medical Center Tufts Medical Center 11571 Beverly Hospital Lahey Health Lahey Health - Beverly Hospital 12468 Brockton Hospital Signature Healthcare Signature Healthcare - Brockton Hospital 12515 Cape Cod Hospital Cape Cod Healthcare Cape Cod Healthcare - Cape Cod Hospital 12516 Falmouth Hosptial Cape Cod Healthcare Cape Cod Healthcare - Falmouth Hosptial 12538 Berkshire Medical Center Berkshire Health Systems Berkshire Health Systems - Berkshire Medical Center 12568 Massachusetts General Hospital Massachusetts General Hospital 12574 Tobey Hospital Southcoast Health Southcoast Health - Tobey Hospital 12576 St. Luke's Hospital Southcoast Health Southcoast Health - St. Luke's Hospital 12578 Charlton Memorial Hospital Southcoast Health Southcoast Health - Charlton Memorial Hospital 12582 Norwood Hospital Steward Health Care Steward Health Care - Norwood Hospital 12588 Saint Anne's Hospital Steward Health Care Steward Health Care - Saint Anne's Hospital 12596 Brigham and Women's Hospital Brigham and Women's Brigham and Women's Hospital 12598 Holyoke Medical Center Holyoke Medical Center 12599 St. Elizabeth's Medical Center Steward Health Care Steward Health Care - St. Elizabeth's Medical Center 12600 Holy Family Hospital Steward Health Care Steward Health Care - Holy Family Hospital 12601 Carney Hospital Steward Health Care Steward Health Care - Carney Hospital 12618 Newton-Wellesley Hospital Newton-Wellesley Hospital 12619 Morton Hospital Steward Health Care Steward Health Care - Morton Hospital 12622 Good Samaritan Medical Center Steward Health Care Steward Health Care - Good Samaritan Medical Center 12630 Boston Medical Center Boston Medical Center 12643 Beth Israel Deaconess Hospital - Plymouth Beth Israel Deaconess Hospital Beth Israel Deaconess Hospital - Plymouth 12654 Winchester Hospital Lahey Health Lahey Health - Winchester Hospital 12670 Emerson Hospital Emerson Hospital 12674 Lowell General Hospital - Main Campus Lowell General Hospital - Main Campus 12679 Lahey Hospital & Medical Center Lahey Health Lahey Health - Lahey Hospital & Medical Center 12685 Anna Jaques Hospital Anna Jaques Hospital 12686 Heywood Hospital Heywood Hospital 12698 Boston Children's Hospital Boston Children's Hospital 12700 HealthAlliance Hospital UMass Memorial Health Care UMass Memorial Health Care - HealthAlliance Hospital 12703 Mount Auburn Hospital Mount Auburn Hospital 12705 Shriners Hospital for Children - Boston Shriners Hospital for Children - Boston 12708 Noble Hospital Baystate Health Noble Hospital 12709 New England Baptist Hospital New England Baptist Hospital 12710 Lawrence Memorial Hospital of Medford Hallmark Health System Hallmark Health System - Lawrence Memorial Hospital of Medford 12714 Lowell General Hospital - Saints Campus Lowell General Hospital - Saints Campus 12751 Clinton Hospital UMass Memorial Health Care UMass Memorial Health Care - Clinton Hospital 12752 Milford Regional Medical Center Milford Regional Medical Center 12778 Franklin Medical Center Baystate Health Baystate Franklin Medical Center 12793 Lawrence General Hospital Lawrence General Hospital 12808 South Shore Hospital South Shore Hospital 12833 Martha's Vineyard Hospital Martha's Vineyard Hospital 12837 Cooley Dickinson Hospital Cooley Dickinson Hospital 12866 Beth Israel Deaconess Hospital - Needham Beth Israel Deaconess Hospital Beth Israel Deaconess Hospital - Needham 12875 Marlborough Hospital UMass Memorial Health Care UMass Memorial Health Care - Marlborough Hospital 12955 Faulkner Hospital Brigham and Women's Brigham and Women's - Faulkner Hospital 13000 Beth Israel Deaconess Medical Center Beth Israel Deaconess Medical Center Beth Israel Deaconess Medical Center 13022 Harrington Memorial Hospital Harrington Memorial Hospital 13049 Mary Lane Hospital Baystate Health Baystate Mary Lane Hospital 13091 Mercy Medical Center Mercy Medical Center 13098 Massachusetts Eye and Ear Infirmary Massachusetts Eye and Ear Infirmary 13116 Salem Hospital North Shore Medical Center North Shore Medical Center - Salem Hospital 13174 Sturdy Memorial Hospital Sturdy Memorial Hospital 13189 Fairview Hospital Berkshire Health Systems Berkshire Health Systems - Fairview Hospital 13201 Framingham Union Hospital MetroWest Medical Center MetroWest Medical Center - Framingham Union Hospital 13206 Nantucket Cottage Hospital Nantucket Cottage Hospital 13213 Cambridge Hospital Cambridge Health Alliance Cambridge Health Alliance - Cambridge Hospital 13215 Everett Hospital Cambridge Health Alliance Cambridge Health Alliance - Everett Hospital 13230 Beth Israel Deaconess Hospital - Milton Beth Israel Deaconess Hospital Beth Israel Deaconess Hospital - Milton 13262 Athol Memorial Hospital Athol Memorial Hospital 13290 Nashoba Valley Medical Center Steward Health Care Steward Health Care - Nashoba Valley Medical Center 13298 Melrose-Wakefield Hospital Hallmark Health System Hallmark Health System - Melrose-Wakefield Hospital 13301 Holy Family Hospital at Merrimack Valley Steward Health Care Steward Health Care - Holy Family Hospital at Merrimack Valley 13309 Leonard Morse Hospital MetroWest Medical Center MetroWest Medical Center - Leonard Morse Hospital 13348 Saint Vincent Hospital Saint Vincent Hospital 13381 Wing Hospital Baystate Health Baystate Wing Hospital 14175 Addison Gilbert Hospital Lahey Health Lahey Health - Addison Gilbert Hospital 14360 Union Hospital North Shore Medical Center North Shore Medical Center - Union Hospital 30172 Dana-Farber Cancer Institute Dana-Farber Cancer Institute Massachusetts Calendar Year 2016 HAI Data Summary

Statewide Hospital Summary This document is designed to help you better understand the data presented on the Summary Page that follow.

Standardized Infection Ratio (SIR): This measure compares the actual number of healthcare-associated infections (HAIs) reported by a location to the predicted number of infections at that location. If a hospital experiences the exact same number of infections as predicted, the SIR has a value of 1. If a hospital experiences more infections, the SIR is greater than 1, and vice versa. Statistical significance means that the number of infections observed was unlikely to have occurred by chance alone. A statistical interpretation of Same or Lower means that the number of infections was comparable or significantly better than expected. An interpretation of Higher means that the number of infections was significantly higher than the expected.

2016 Hospital Survey Statistics

These statistics aim to provide a broad sense of patient care capacity and staffing in Massachusetts acute care hospitals. Every hospital in Massachusetts has Infection Preventionists who work to reduce healthcare-associated infections at their hospital. The Society for Healthcare Epidemiology of America (SHEA) recommends that there be at least one Infection Preventionist per 125 hospital beds.

Central Line-Associated Blood Stream Infection

The CLABSI SIR table shows data by ICU type. The risk of infection can vary greatly from one ICU to another depending on the type of patients in the unit and the type of treatment received. In addition to adult and pediatric ICUs, 10 hospitals in the state have neonatal ICUs, or NICUs. Each location strives for zero infections. The data presented in this table is from calendar year 2016 (January 1, 2016 through December 31, 2016). The predicted number of infections is calculated based on 2015 national HAI aggregate data and adjusted for each facility using variables found to be significant predictors of HAI incidence. SIRs can only be calculated using this new baseline from calendar year 2015 and forward. Therefore, you will not see data for calendar year 2014 or earlier. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have been suppressed (not calculable).

The central line utilization ratio measures how often and for The State CLABSI SIR chart shows how the state SIR has changed how long acute care patients have a central venous catheter in over time across three ICU types. The SIRs in this chart use place. This statistic is important because fewer central lines predicted values calculated using a negative binomial regression mean fewer chances for infection. A downward trend may model generated from nationally aggregated data from calendar indicate that hospitals across the state have implemented year 2015. As CLABSIs are prevented, the state SIRs should interventions to try to reduce CLABSIs by removing central decrease. lines when not absolutely necessary.

Catheter-Associated Urinary Tract Infection

The CAUTI SIR table shows data by ICU type. The risk of infection can vary greatly from one ICU to another depending on the type of patients in the unit and the type of treatment received. Each location strives for zero infections. The data presented in this table is from calendar year 2016 (January 1, 2016 through December 31, 2016). The predicted number of infections is calculated based on 2015 national HAI aggregate data and adjusted for each facility using variables found to be significant predictors of HAI incidence. SIRs can only be calculated using this new baseline from calendar year 2015 and forward. Therefore, you will not see data for calendar year 2014 or earlier. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have been suppressed (not calculable).

The catheter utilization ratio measures how often and for how The State CAUTI SIR chart shows how the state SIR has changed long acute care patients have a urinary catheter in place. This over time across two ICU types. The SIRs in this chart use statistic is important because fewer urinary catheters mean predicted values calculated using a negative binomial regression fewer chances for infection. A downward trend may indicate model generated from nationally aggregated data from calendar that hospitals across the state have implemented interventions year 2015. As CAUTIs are prevented, the state SIRs should to try to reduce CAUTIs by removing urinary catheters when decrease. not absolutely necessary.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: July 2017

Statewide Hospital Summary

Surgical Site Infection

SSI data are reported by procedure type since the risk of infection can vary greatly from one procedure to the next depending on individual patient and hospital factors. All deep incisional primary and organ/space infections are included in this report. Procedures with implants are observed for infection for 90 days after the procedure. These procedures included CABG, HPRO, and KPRO procedures. Abdominal hysterectomies, vaginal hysterectomies and colon procedures are observed for 30 days after procedure.

The SSI SIR table contains hospital data for 2016 for each procedure currently under surveillance. Each hospital strives for zero infections. The predicted number of infections is calculated based on 2015 national HAI aggregate data and adjusted for each procedure using variables found to be significant predictors of HAI incidence. SIRs can only be calculated using this new baseline from calendar year 2015 and forward. Therefore, you will not see data for calendar year 2014 or earlier. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have been suppressed (not calculable).

The chart included depicts SSI statistical interpretations for calendar year 2015 through 2016. It is meant to be used as a quick assessment of significant variation of infection rates over time. This chart does not capture changes in infection rates that were not statistically significant.

Facility Wide LabID Events

The LabID event section includes overall inpatient facility-wide (FacWideIn) Clostridium difficile infection (CDI) and methicillin- resistant Staphylococcus aureus (MRSA) bacteremia surveillance LabID event data reported from acute care facilities. LabID events are provided as proxy surveillance measures of healthcare infection acquisition, exposure burden, and infection burden, based on laboratory and limited admission data, and should be evaluated as such. When interpreting pediatric CDI data, asymptomatic colonization in children less than one year of age may confound pediatric CDI rates.

The CDI and MRSA SIR table contains hospital data for 2016 for each LabID event currently under surveillance. Each hospital strives for zero infections. The predicted number of infections is calculated based on 2015 national HAI aggregate data and adjusted for each facility using variables found to be significant predictors of HAI incidence. SIRs can only be calculated using this new baseline from calendar year 2015 and forward. Therefore, you will not see data for calendar year 2014 or earlier. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have been suppressed (not calculable).

The chart included depicts LabID statistical interpretations for calendar year 2015 through 2016. It is meant to be used as a quick assessment of significant variation of infection rates over time. This chart does not capture change in infection rates that were not statistically significant.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Statewide Hospital Summary

2016 Hospital Survey Statistics

Small Hospital Medium Hospital Large Hospital <100 Beds 100-299 Beds 300+ Beds Number of Hospitals 22 36 13 Medical School Affiliation 23% 61% 85% Average Number of Beds 58 184 544 Average Number of ICU Beds 5 14 90 Avergae Number of Admissions 3,003 10,306 32,272 Avergae Number of Patient Days 12,602 49,663 161,430 Beds per Infection Preventionist 54.9 128.7 136.6 Central Line-Associated Blood Stream Infection CLABSI SIRs by ICU Type for 2016 Calendar Year Number Predicted Confidence ICU Type Infections Central Line Days SIR Interpretation of ICUs Infections Interval Burn 1 9 1,228 4.17 2.16 (1.05 - 3.96) Higher Cardiac 8 14 13,882 15.17 0.92 (0.52 - 1.51) Same Cardiothoracic 11 21 23,921 26.26 0.80 (0.50 - 1.20) Same Medical 15 29 33,096 37.17 0.78 (0.53 - 1.10) Same (major teaching) Medical 4 2 3,132 2.53 0.79 (0.13 - 2.61) Same (not major teaching) Medical/Surgical 12 8 19,636 21.48 0.37 (0.17 - 0.70) Lower (major teaching) Medical/Surgical 40 21 33,363 27.02 0.78 (0.49 - 1.16) Same (not major teaching) Neurosurgical 3 4 4,751 5.36 0.75 (0.23 - 1.80) Same Pediatric 9 43 20,057 32.31 1.33 (0.97 - 1.77) Same Surgical 14 20 30,930 34.12 0.59 (0.36 - 0.88) Lower Trauma 3 5 4,468 6.83 0.73 (0.26 - 1.62) Same Neonatal 10 26 16,389 23.34 1.11 (0.74 - 1.60) Same

State CLABSI SIRs Compared to National Average State Central Line Utilization Ratios

2 0.8 Adult Adult

1.5 0.6

1 Pediatric 0.4 Pediatric SIR 0.5 Neonatal 0.2 Neonatal

0 Ratio Utilization 0 2015 2016 2015 2016 Catheter-Associated Urinary Tract Infection CAUTI SIRs by ICU Type for 2016 Calendar Year Number Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation of ICUs Infections Interval Burn 1 2 1,084 3.71 0.54 (0.09 - 1.78) Same Cardiac 8 24 13,830 20.97 1.14 (0.75 - 1.67) Same Cardiothoracic 11 25 24,623 30.66 0.82 (0.53 - 1.18) Same Medical 15 41 36,697 48.64 0.84 (0.61 - 1.13) Same (major teaching) Medical 4 4 5,238 4.14 0.97 (0.30 - 2.33) Same (not major teaching) Medical/Surgical 12 22 25,195 31.01 0.71 (0.45 - 1.05) Same (major teaching) Medical/Surgical 40 45 51,577 41.66 1.08 (0.79 - 1.43) Same (not major teaching) Neurosurgical 3 30 7,401 26.24 1.14 (0.78 - 1.61) Same Pediatric 9 9 7,610 12.07 0.75 (0.36 - 1.36) Same Surgical 14 62 39,401 70.50 0.88 (0.68 - 1.12) Same Trauma 3 26 6,759 18.53 1.40 (0.93 - 2.02) Same

State CAUTI SIRs Compared to National Average State Catheter Utilization Ratios

1.5 0.8

Adult 0.6 Adult

0.4 SIR 0.5 Pediatric 0.2 Pediatric

0 Ratio Utilization 0 2015 2016 2015 2016 1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Statewide Hospital Summary

Surgical Site Infection SSI SIRs by Procedure Type for 2016 Calendar Year Hospitals Predicted Confidence Procedure Infections Procedures SIR Interpretation Reporting Infections Interval Coronary Artery Bypass Graft (CABG) 14 23 4,114 32.56 0.71 (0.45 - 1.04) Same Knee Prosthesis (KPRO) 60 76 16,993 53.79 1.41 (1.12 - 1.75) HIgher Hip Prosthesis (HPRO) 59 83 12,780 69.21 1.20 (0.96 - 1.47) Same Abdominal Hysterectomy (HYST) 54 46 4,550 32.26 1.43 (1.05 - 1.88) Higher Vaginal Hysterectomy (VHYS) 51 21 1,607 9.38 2.24 (1.42 - 3.36) Higher Colon Surgery (COLO) 62 158 7,128 176.59 0.89 (0.76 - 1.04) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 CABG KPRO HPRO HYST VHYS COLO

Facility Wide LabID Events CDI and MRSA SIRs for 2016 Calendar Year Hospitals Predicted Confidence Event Infections Patient Days SIR Interpretation Reporting Infections Interval Clostridium difficile (CDI) 70 2,372 3,411,628 2,509 0.95 (0.90 - 0.98) Lower Methicillin-resistant Staphylococcus (MRSA) 70 123 3,700,493 206 0.60 (0.49 - 0.70) Lower aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 CDI MRSA

2 Massachusetts Calendar Year 2016 HAI Data Summary Hospital-Specific Summaries

This document is designed to help you better understand the data presented on the Summary Pages that follow. Standardized Infection Ratio (SIR): This measure compares the actual number of healthcare-associated infections (HAIs) reported by a location to the predicted number of infections at that location. If a hospital experiences the exact same number of infections as predicted, the SIR has a value of 1. If a hospital experiences more infections, the SIR is greater than 1, and vice versa. Statistical significance means that the number of infections observed was unlikely to have occurred by chance alone. A statistical interpretation of Same or Lower means that the number of infections was comparable or significantly better than expected. An interpretation of Higher means that the number of infections was significantly higher than the expected. Hospital Survey Statistics HCP Influenza Vaccination Coverage

These statistics aim to provide a broad sense of a hospital’s For the 2016-2017 influenza season, MA hospitals were required by patient care capacity and staffing. When reviewing these data, MDPH and the Centers for Medicare and Medicaid Services (CMS) to keep in mind that a single infection at a smaller hospital may have report detailed vaccination data on their healthcare personnel (HCP) a greater impact on infection rates than at a larger hospital. Every via the NHSN. The percent of HCP by vaccination status for the hospital in Massachusetts has Infection Preventionists who work to hospital are presented in comparison to the state median. reduce healthcare-associated infections at their hospital. The Massachusetts expected that a 90% influenza vaccination rate Society for Healthcare Epidemiology of America (SHEA) would be reached for acute care hospital employees. Vaccination recommends that there be at least one Infection Preventionist per rates include those vaccinated both within and outside of the 125 beds at a hospital. hospital.

Central Line-Associated Blood Stream Infection

The Hospital CLABSI SIR table shows data by ICU type. The risk of infection can vary greatly from one ICU to another depending on the type of patients in the unit and the type of treatment received. Each location strives for zero infections. The data presented in this table is from calendar year 2016 (January 1, 2016 through December 31, 2016). The predicted number of infections is calculated based on 2015 national HAI aggregate data and adjusted for each facility using variables found to be significant predictors of HAI incidence. SIRs can only be calculated using this new baseline from calendar year 2015 and forward. Therefore, you will not see data for calendar year 2014 or earlier. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have been suppressed (not calculable).

The central line utilization ratio measures how often and for how The Hospital and State CLABSI SIR chart shows how the hospital long acute care patients have a central venous catheter in place. SIR and the state SIR have changed over time across all ICU types. This statistic is important because fewer central lines mean fewer The state line represents the SIR among comparable ICU types in chances for infection. A downward trend may indicate that a the state. The SIRs in this chart use predicted values calculated hospital has implemented an intervention to reduce CLABSIs by using a negative binomial regression model generated from removing central lines when not absolutely necessary. An upward nationally aggregated data from calendar year 2015. As CLABSIs trend does not necessarily indicate a change that is within the are prevented, the SIR for a hospital should decrease. hospital’s control. The state line represents central line utilization among comparable adult ICUs in the state.

Catheter-Associated Urinary Tract Infection

The Hospital CAUTI SIR table shows data by ICU type. The risk of infection can vary greatly from one ICU to another depending on the type of patients in the unit and the type of treatment received. Each location strives for zero infections. The data presented in this table is from calendar year 2016 (January 1, 2016 through December 31, 2016). The predicted number of infections is calculated based on 2015 national HAI aggregate data and adjusted for each facility using variables found to be significant predictors of HAI incidence. SIRs can only be calculated using this new baseline from calendar year 2015 and forward. Therefore, you will not see data for calendar year 2014 or earlier. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have been suppressed (not calculable).

The central line utilization ratio measures how often and for how The Hospital and State CAUTI SIR chart shows how the hospital long acute care patients have a urinary catheter in place. This SIR and the state SIR have changed over time across all ICU types. statistic is important because fewer urinary catheters mean fewer The state line represents the SIR among comparable ICU types in chances for infection. A downward trend may indicate that a the state. The SIRs in this chart use predicted values calculated hospital has implemented an intervention to reduce CAUTIs by using a negative binomial regression model generated from removing urinary catheters when not absolutely necessary. An nationally aggregated data from calendar year 2015. As CAUTIs upward trend does not necessarily indicate a change that is within are prevented, the SIR for a hospital should decrease. the hospital’s control. The state line represents urinary catheter utilization among comparable adult ICUs in the state.

1 Massachusetts Calendar Year 2016 HAI Data Summary

Hospital-Specific Summaries

Surgical Site Infection

SSI data are reported by procedure type since the risk of infection can vary greatly from one procedure to the next depending on individual patient and hospital factors. All deep incisional primary and organ/space infections are included in this report. Procedures with implants are observed for infection for 90 days after the procedure. These procedures include CABG, HPRO, and KPRO procedures. Abdominal hysterectomies, vaginal hysterectomies and colon procedures are observed for 30 days after procedure.

The Hospital SSI SIR table contains hospital data for 2016 for each procedure currently under surveillance. Each hospital strives for zero infections. The predicted number of infections is calculated based on 2015 national HAI aggregate data and adjusted for each facility using variables found to be significant predictors of HAI incidence. SIRs can only be calculated using this new baseline from calendar year 2015 and forward. Therefore, you will not see data for calendar year 2014 or earlier. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have been suppressed (not calculable).

Facility Wide LabID Events

The LabID event section includes overall inpatient facility-wide (FacWideIn) Clostridium difficile infection (CDI) and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia surveillance LabID event data reported from acute care facilities. LabID events are provided as proxy surveillance measures of healthcare infection acquisition, exposure burden, and infection burden, based on laboratory and limited admission data, and should be evaluated as such. When interpreting pediatric CDI data, asymptomatic colonization in children less than one year of age may confound pediatric CDI rates.

The Hospital CDI and MRSA SIR table contains hospital data for 2016 for each LabID event currently under surveillance. Each hospital strives for zero infections. The predicted number of infections is calculated based on 2015 national HAI aggregate data and adjusted for each facility using variables found to be significant predictors of HAI incidence. SIRs can only be calculated using this new baseline from calendar year 2015 and forward. Therefore, you will not see data for calendar year 2014 or earlier. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have been suppressed (not calculable).

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Baystate Medical Center - Springfield, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 769 Medical contraindication Number of ICU Beds 124 80% 92% 97% Number of Admissions 41,421 70% Declined vaccine Number of Patient Days 200,531 60% Vaccine coverage Beds per Infection Preventionist 134.91 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Cardiac 4 1,073 1.21 3.30 (1.05 - 7.97) Higher Cardiothoracic 0 1,748 1.97 0.00 (0 - 1.51) Same Medical (major teaching) 2 2,286 2.58 0.78 (0.13 - 2.56) Same Pediatric 1 497 0.72 1.40 (0.07 - 6.89) Same Surgical 0 998 1.13 0.00 (0 - 2.66) Same Neonatal 2 2,132 3.07 0.65 (0.10 - 2.15) Same

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.8

Adult 0.6 Hospital Pediatric

0.5 0.4 Ratio SIR State Neonatal Utilization 0.2 State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Catheter-Associated Urinary Tract Infection Hospital CAUTI SIRs by ICU Type for 2016 Calendar Year Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation Infections Interval Cardiac 5 1223 1.95 2.56 (0.93 - 5.67) Same Cardiothoracic 2 1642 2.14 0.94 (0.15 - 3.08) Same Medical (major teaching) 7 3301 4.37 1.60 (0.7 - 3.16) Same Pediatric 1 332 0.57 1.76 (0.08 - 8.65) Same Surgical 7 1766 3.22 2.17 (0.95 - 4.29) Same

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.5 0.8

Adult 2.0 0.6

1.5 Hospital

0.4 Pediatric Ratio SIR 1.0 State 0.5 Utilization 0.2 State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Baystate Medical Center - Springfield, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 3 458 4.69 0.64 (0.16 - 1.74) Same Knee Prosthesis (KPRO) 2 700 2.67 0.75 (0.12 - 2.47) Same Hip Prosthesis (HPRO) 2 431 3.15 0.64 (0.10 - 2.09) Same Abdominal Hysterectomy (HYST) 8 453 3.12 2.57 (1.19 - 4.87) Higher Vaginal Hysterectomy (VHYS) 7 222 1.64 4.26 (1.86 - 8.42) Higher Colon Surgery (COLO) 21 432 13.69 1.53 (0.97 - 2.30) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 CABG KPRO HPRO HYST VHYS COLO *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 67 164,521 142.00 0.47 (0.36 - 0.59) Lower Methicillin-resistant Staphylococcus (MRSA) 4 185,634 15.95 0.25 (0.08 - 0.60) Lower aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 UMass Memorial Health Care - UMass Memorial Medical Center - Worcester, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 717 Medical contraindication Number of ICU Beds 141 80% 70% 92% Number of Admissions 45,232 84% Declined vaccine Number of Patient Days 272,975 60% Vaccine coverage Beds per Infection Preventionist 119.50 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Cardiothoracic 1 1,982 2.24 0.45 (0.02 - 2.20) Same Medical (major teaching) 4 6,850 7.73 0.52 (0.16 - 1.24) Same Pediatric 1 363 0.52 1.91 (0.09 - 9.43) Same Surgical 0 3,703 4.18 0.00 (0 - 0.71) Lower Trauma 2 1,532 2.34 0.86 (0.14 - 2.82) Same Neonatal 0 1,825 2.54 0.00 (0 - 1.18) Same

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6

Adult

Hospital 0.4 Pediatric

0.5 Ratio SIR State 0.2 Neonatal Utilization State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Catheter-Associated Urinary Tract Infection Hospital CAUTI SIRs by ICU Type for 2016 Calendar Year Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation Infections Interval Cardiothoracic 3 2210 2.88 1.04 (0.26 - 2.83) Same Medical (major teaching) 9 8381 11.11 0.81 (0.39 - 1.48) Same Pediatric 1 216 0.37 Not calculable Surgical 3 4670 8.52 0.35 (0.09 - 0.95) Lower Trauma 6 2970 8.14 0.74 (0.29 - 1.53) Same

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.5 0.8

Adult 0.6

1.0 Hospital

0.4 Pediatric Ratio SIR 0.5 State Utilization 0.2 State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 UMass Memorial Health Care - UMass Memorial Medical Center - Worcester, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 0 242 1.86 0.00 (0 - 1.60) Same Knee Prosthesis (KPRO) 1 353 1.21 0.83 (0.04 - 4.08) Same Hip Prosthesis (HPRO) 1 318 2.33 0.43 (0.02 - 2.11) Same Abdominal Hysterectomy (HYST) 0 165 1.23 0.00 (0 - 2.44) Same Vaginal Hysterectomy (VHYS) 0 56 0.41 Not calculable Colon Surgery (COLO) 3 252 6.56 0.46 (0.11 - 1.24) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 86 200,515 142.94 0.60 (0.48 - 0.73) Lower Methicillin-resistant Staphylococcus (MRSA) 4 218,359 16.87 0.24 (0.07 - 0.57) Lower aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Tufts Medical Center - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 382 Medical contraindication Number of ICU Beds 98 80% 92% 96% Number of Admissions 17,958 70% Declined vaccine Number of Patient Days 105,685 60% Vaccine coverage Beds per Infection Preventionist 127.33 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Cardiac 2 1,794 2.02 0.99 (0.16 - 3.26) Same Cardiothoracic 2 2,615 2.95 0.68 (0.11 - 2.24) Same Medical (major teaching) 2 2,065 2.33 0.86 (0.14 - 2.83) Same Neurosurgical 2 944 1.07 1.88 (0.31 - 6.20) Same Pediatric 1 753 1.08 0.92 (0.04 - 4.55) Same Surgical 1 1,826 2.06 0.49 (0.02 - 2.39) Same Neonatal 3 2,551 3.82 0.79 (0.2 - 2.13) Same

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.8

Adult 0.6 Hospital Pediatric

Catheter-Associated Urinary Tract Infection Hospital CAUTI SIRs by ICU Type for 2016 Calendar Year Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation Infections Interval Cardiac 3 1178 1.88 1.59 (0.40 - 4.33) Same Cardiothoracic 3 2286 2.98 1.01 (0.25 - 2.74) Same Medical (major teaching) 0 1931 2.56 0.00 (0 - 1.17) Same Neurosurgical 3 1412 5.01 0.60 (0.15 - 1.63) Same Pediatric 1 322 0.55 1.81 (0.09 - 8.92) Same Surgical 2 1828 3.34 0.60 (0.10 - 1.98) Same

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.5 0.8

Adult 0.6

1.0 Hospital

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Tufts Medical Center - Boston, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 6 322 3.29 1.83 (0.74 - 3.79) Same Knee Prosthesis (KPRO) 3 232 1.00 3.01 (0.76 - 8.18) Same Hip Prosthesis (HPRO) 3 194 1.84 1.63 (0.41 - 4.43) Same Abdominal Hysterectomy (HYST) 1 110 0.90 1.12 (0.05 - 5.50) Same Vaginal Hysterectomy (VHYS) 0 32 0.24 Not calculable Colon Surgery (COLO) 6 157 4.91 1.22 (0.49 - 2.54) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 76 89,698 63.56 1.20 (0.94 - 1.48) Same Methicillin-resistant Staphylococcus (MRSA) 1 96,245 7.80 0.13 (0.00 - 0.63) Lower aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lahey Health - Beverly Hospital - Beverly, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 223 Medical contraindication Number of ICU Beds 14 80% 92% Number of Admissions 21,970 70% 91% Declined vaccine Number of Patient Days 75,180 60% Vaccine coverage Beds per Infection Preventionist 111.50 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 1,410 1.06 0.00 (0 - 2.82) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.4 Adult

1.0 Hospital 0.38 Ratio SIR 0.5 State 0.36

Utilization State (Adult) 0.0 0.34 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.7 1.5 0.65 Adult

Hospital

1.0 0.6 Ratio SIR State

0.5 Utilization 0.55 State (Adult) 0.0 0.5 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lahey Health - Beverly Hospital - Beverly, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 2 550 1.31 1.53 (0.25 - 5.03) Same Hip Prosthesis (HPRO) 0 32 0.12 Not calculable Abdominal Hysterectomy (HYST) 1 34 0.23 Not calculable Vaginal Hysterectomy (VHYS) 1 39 0.16 Not calculable Colon Surgery (COLO) 5 113 2.78 1.80 (0.65 - 3.98) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 KPRO HPRO HYST VHYS COLO *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 47 71,779 43.54 1.08 (0.80 - 1.42) Same Methicillin-resistant Staphylococcus (MRSA) 0 80,090 2.58 0.00 (0 - 1.16) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Signature Healthcare - Brockton Hospital - Brockton, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 216 Medical contraindication Number of ICU Beds 16 80% 92% 93% Number of Admissions 9,427 70% Declined vaccine Number of Patient Days 54,481 60% Vaccine coverage Beds per Infection Preventionist 108.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 1,776 1.55 0.00 (0 - 1.92) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.6 Adult

1.0 Hospital 0.4 Ratio SIR 0.5 State 0.2

Utilization State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

0.5 Utilization 0.2 State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Signature Healthcare - Brockton Hospital - Brockton, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 173 0.56 0.00 (0 - 5.38) Same Hip Prosthesis (HPRO) 0 147 0.72 0.00 (0 - 4.18) Same Abdominal Hysterectomy (HYST) 0 20 0.18 Not calculable Vaginal Hysterectomy (VHYS) 0 3 0.01 Not calculable Colon Surgery (COLO) 3 77 1.54 1.95 (0.49 - 5.29) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 23 39,592 29.66 0.78 (0.50 - 1.14) Same Methicillin-resistant Staphylococcus (MRSA) 0 47,756 2.29 0.00 (0 - 1.30) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Cape Cod Healthcare - Cape Cod Hospital - Hyannis, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 246 Medical contraindication Number of ICU Beds 22 80% 92% Number of Admissions 20,983 70% 85% Declined vaccine Number of Patient Days 75,415 60% Vaccine coverage Beds per Infection Preventionist 246.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Cardiothoracic 2 1,252 1.09 1.84 (0.30 - 6.08) Same Medical/Surgical 1 1,058 0.92 1.09 (0.05 - 5.37) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 2.0 0.4 1.5 Adult Hospital 0.38

1.0 Ratio SIR State 0.36

0.5 Utilization State (Adult) 0.0 0.34 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Catheter-Associated Urinary Tract Infection Hospital CAUTI SIRs by ICU Type for 2016 Calendar Year Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation Infections Interval Cardiothoracic 3 2131 1.91 1.57 (0.4 - 4.27) Same Medical/Surgical 2 2181 1.95 1.02 (0.17 - 3.38) Same (not major teaching)

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.75 1.5 0.7 Adult

Hospital

1.0 0.65 Ratio SIR State

0.5 Utilization 0.6 State (Adult) 0.0 0.55 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Cape Cod Healthcare - Cape Cod Hospital - Hyannis, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 0 142 0.65 0.00 (0 - 4.60) Same Knee Prosthesis (KPRO) 0 405 1.16 0.00 (0 - 2.57) Same Hip Prosthesis (HPRO) 4 347 1.80 2.23 (0.70 - 5.37) Same Abdominal Hysterectomy (HYST) 0 66 0.35 Not calculable Vaginal Hysterectomy (VHYS) 0 81 0.34 Not calculable Colon Surgery (COLO) 2 197 4.63 0.43 (0.07 - 1.42) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 52 73,075 49.08 1.06 (0.79 - 1.37) Same Methicillin-resistant Staphylococcus (MRSA) 1 75,055 3.25 0.31 (0.01 - 1.51) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Cape Cod Healthcare - Falmouth Hospital - Falmouth, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 95 Medical contraindication Number of ICU Beds 10 80% 70% 92% Number of Admissions 9,089 83% Declined vaccine Number of Patient Days 27,490 60% Vaccine coverage Beds per Infection Preventionist 118.75 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 4 1,081 0.81 4.91 (1.56 - 11.84) Higher (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 6.0 0.6 Adult

4.0 Hospital 0.4 Ratio SIR 2.0 State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 4.0 0.8 3.0 0.6 Adult

Hospital

2.0 0.4 Ratio SIR State

1.0 Utilization 0.2 State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Cape Cod Healthcare - Falmouth Hospital - Falmouth, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 294 0.66 0.00 (0 - 4.53) Same Hip Prosthesis (HPRO) 3 230 0.93 3.24 (0.82 - 8.81) Same Abdominal Hysterectomy (HYST) 0 26 0.13 Not calculable Vaginal Hysterectomy (VHYS) 0 55 0.23 Not calculable Colon Surgery (COLO) 0 52 1.08 0.00 (0 - 2.77) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 17 26,292 17.13 0.99 (0.59 - 1.55) Same Methicillin-resistant Staphylococcus (MRSA) 0 27,490 1.31 0.00 (0 - 2.28) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Berkshire Health Systems - Berkshire Medical Center - Pittsfield, MA

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 0.5 0.55 Adult

Hospital 0.5

0.3 Ratio SIR State 0.45

Utilization State (Adult) 0.0 0.4 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.75 Adult

Hospital 0.7

1.0 Ratio SIR State 0.65 0.5 Utilization 0.6 State (Adult) 0.0 0.55 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Berkshire Health Systems - Berkshire Medical Center - Pittsfield, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 1 315 0.94 1.06 (0.05 - 5.22) Same Hip Prosthesis (HPRO) 3 204 1.30 2.31 (0.58 - 6.29) Same Abdominal Hysterectomy (HYST) 1 28 0.14 Not calculable Vaginal Hysterectomy (VHYS) 1 19 0.14 Not calculable Colon Surgery (COLO) 2 73 1.64 1.22 (0.20 - 4.03) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 38 51,756 41.97 0.91 (0.65 - 1.23) Same Methicillin-resistant Staphylococcus (MRSA) 4 55,341 2.63 1.52 (0.48 - 3.67) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Massachusetts General Hospital - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 993 Medical contraindication Number of ICU Beds 146 80% 70% 92% Number of Admissions 49,860 84% Declined vaccine Number of Patient Days 308,742 60% Vaccine coverage Beds per Infection Preventionist 110.33 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Burn 9 1,228 4.17 2.16 (1.05 - 3.96) Higher Cardiac 3 4,014 4.53 0.66 (0.16 - 1.80) Same Cardiothoracic 5 4,419 4.99 1.00 (0.36 - 2.22) Same Medical (major teaching) 3 4,614 5.21 0.58 (0.14 - 1.56) Same Neurosurgical 2 3,153 3.56 0.56 (0.09 - 1.85) Same Pediatric 1 1,207 1.74 0.58 (0.02 - 2.83) Same Surgical 6 7,422 8.37 0.72 (0.29 - 1.49) Same Neonatal 2 1,677 2.42 0.83 (0.13 - 2.73) Same

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.8

Adult 0.6 Hospital Pediatric

Catheter-Associated Urinary Tract Infection Hospital CAUTI SIRs by ICU Type for 2016 Calendar Year Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation Infections Interval Burn 2 1084 3.71 0.54 (0.09 - 1.78) Same Cardiac 1 3463 5.53 0.18 (0.00 - 0.89) Lower Cardiothoracic 2 4389 5.72 0.35 (0.05 - 1.15) Same Medical (major teaching) 1 5249 6.96 0.14 (0.00 - 0.70) Lower Neurosurgical 19 5060 17.94 1.06 (0.65 - 1.62) Same Pediatric 2 779 1.34 1.50 (0.25 - 4.94) Same Surgical 9 9101 16.61 0.54 (0.26 - 0.99) Lower

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.5 1

Adult

1.0 Hospital

0.5 Pediatric Ratio SIR 0.5 State Utilization State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Massachusetts General Hospital - Boston, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 4 525 4.94 0.81 (0.25 - 1.95) Same Knee Prosthesis (KPRO) 6 803 2.60 2.31 (0.93 - 4.80) Same Hip Prosthesis (HPRO) 8 657 4.19 1.91 (0.88 - 3.62) Same Abdominal Hysterectomy (HYST) 9 602 4.58 1.96 (0.95 - 3.60) Same Vaginal Hysterectomy (VHYS) 0 38 0.28 Not calculable Colon Surgery (COLO) 22 712 21.55 1.02 (0.65 - 1.52) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 271 282,852 276.92 0.98 (0.86 - 1.10) Same Methicillin-resistant Staphylococcus (MRSA) 20 300,381 22.99 0.87 (0.54 - 1.31) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Southcoast Health - Tobey Hospital - Wareham, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 74 Medical contraindication Number of ICU Beds 10 80% 92% 93% Number of Admissions 6,575 70% Declined vaccine Number of Patient Days 19,172 60% Vaccine coverage Beds per Infection Preventionist 185.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 756 0.51 0.00 (0 - 5.90) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.4 Adult

Hospital 0.38

0.5 Ratio SIR State 0.36

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.5 0.8 2.0 0.6 Adult

1.5 Hospital

0.4 Ratio SIR 1.0 State 0.5 Utilization 0.2 State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Southcoast Health - Tobey Hospital - Wareham, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 1 35 0.08 Not calculable Hip Prosthesis (HPRO) 0 22 0.09 Not calculable Abdominal Hysterectomy (HYST) 0 27 0.14 Not calculable Vaginal Hysterectomy (VHYS) 0 8 0.03 Not calculable Colon Surgery (COLO) 0 44 0.66 0.00 (0 - 4.52) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 8 19,172 11.10 0.72 (0.33 - 1.36) Same Methicillin-resistant Staphylococcus (MRSA) 0 20,209 0.64 0.00 (0 - 4.69) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Southcoast Health - St. Luke's Hospital - New Bedford, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 391 Medical contraindication Number of ICU Beds 32 80% 92% Number of Admissions 18,692 70% 88% Declined vaccine Number of Patient Days 74,517 60% Vaccine coverage Beds per Infection Preventionist 279.29 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 3 2,936 2.55 1.18 (0.3 - 3.20) Same (not major teaching) Surgical 0 1,394 1.21 0.00 (0 - 2.47) Same

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.8 0.6 Adult Hospital

0.5 0.4 Ratio SIR State

Utilization 0.2 State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.5 0.7 2.0 0.65 Adult

1.5 Hospital

0.6 Ratio SIR 1.0 State

Utilization State (Adult) 0.5 0.55 0.0 0.5 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Southcoast Health - St. Luke's Hospital - New Bedford, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 165 0.46 Not calculable Hip Prosthesis (HPRO) 1 158 0.91 1.10 (0.05 - 5.43) Same Abdominal Hysterectomy (HYST) 1 97 0.50 1.98 (0.09 - 9.78) Same Vaginal Hysterectomy (VHYS) 1 63 0.26 Not calculable Colon Surgery (COLO) 2 115 2.18 0.92 (0.15 - 3.03) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 44 74,517 55.19 0.80 (0.58 - 1.06) Same Methicillin-resistant Staphylococcus (MRSA) 2 79,797 2.99 0.67 (0.11 - 2.20) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Southcoast Health - Charlton Memorial Hospital - Fall River, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 328 Medical contraindication Number of ICU Beds 32 80% 92% Number of Admissions 17,495 70% 91% Declined vaccine Number of Patient Days 67,304 60% Vaccine coverage Beds per Infection Preventionist 273.33 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Cardiac 1 1,357 1.18 0.85 (0.04 - 4.18) Same Cardiothoracic 0 1,526 1.32 0.00 (0 - 2.26) Same Medical 1 1,637 1.42 0.70 (0.03 - 3.47) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.8 0.6 Adult Hospital

0.5 0.4 Ratio SIR State

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.0 0.8 Adult

Hospital 0.75

0.5 Ratio SIR State 0.7

Utilization State (Adult) 0.0 0.65 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Southcoast Health - Charlton Memorial Hospital - Fall River, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 1 275 1.49 0.67 (0.03 - 3.30) Same Knee Prosthesis (KPRO) 1 181 0.47 Not calculable Hip Prosthesis (HPRO) 2 118 0.61 3.28 (0.55 - 10.84) Same Abdominal Hysterectomy (HYST) 0 143 0.83 0.00 (0 - 3.59) Same Vaginal Hysterectomy (VHYS) 1 60 0.25 Not calculable Colon Surgery (COLO) 3 128 2.57 1.17 (0.29 - 3.17) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 42 67,304 46.76 0.90 (0.65 - 1.20) Same Methicillin-resistant Staphylococcus (MRSA) 2 72,902 2.44 0.82 (0.13 - 2.71) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Norwood Hospital - Norwood, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status For-profit 90% Unknown status Number of Beds 244 Medical contraindication Number of ICU Beds 11 80% 92% Number of Admissions 10,904 70% 91% Declined vaccine Number of Patient Days 54,056 60% Vaccine coverage Beds per Infection Preventionist 244.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 934 0.81 0.00 (0 - 3.69) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 3.0 1 Adult

2.0 Hospital

0.5 Ratio SIR 1.0 State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Norwood Hospital - Norwood, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 2 143 0.47 Not calculable Hip Prosthesis (HPRO) 6 119 0.59 10.19 (4.13 - 21.19) Higher Abdominal Hysterectomy (HYST) 0 32 0.23 Not calculable Vaginal Hysterectomy (VHYS) 0 6 0.03 Not calculable Colon Surgery (COLO) 3 89 1.71 1.75 (0.44 - 4.76) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 34 31,401 26.58 1.28 (0.9 - 1.76) Same Methicillin-resistant Staphylococcus (MRSA) 1 32,639 1.36 0.74 (0.03 - 3.62) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Saint Anne's Hospital - Fall River, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status For-profit 90% Unknown status Number of Beds 185 Medical contraindication Number of ICU Beds 12 80% 92% Number of Admissions 9,774 70% 90% Declined vaccine Number of Patient Days 48,553 60% Vaccine coverage Beds per Infection Preventionist 185.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 961 0.72 0.00 (0 - 4.13) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.4 Adult

Hospital

0.5 0.35 Ratio SIR State

Utilization State (Adult) 0.0 0.3 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.65 1.5 Adult 0.6 Hospital

1.0 Ratio SIR State 0.55

0.5 Utilization State (Adult) 0.0 0.5 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Saint Anne's Hospital - Fall River, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 8 406 0.81 9.86 (4.58 - 18.72) Higher Hip Prosthesis (HPRO) 2 225 0.64 3.13 (0.52 - 10.33) Same Abdominal Hysterectomy (HYST) 0 13 0.07 Not calculable Vaginal Hysterectomy (VHYS) 1 13 0.05 Not calculable Colon Surgery (COLO) 1 64 1.00 1.00 (0.05 - 4.90) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 39 37,614 25.71 1.52 (1.09 - 2.05) Higher Methicillin-resistant Staphylococcus (MRSA) 2 37,614 1.56 1.28 (0.21 - 4.22) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Brigham and Women's Hospital - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 763 Medical contraindication Number of ICU Beds 156 80% 92% Number of Admissions 50,322 70% 91% Declined vaccine Number of Patient Days 263,558 60% Vaccine coverage Beds per Infection Preventionist 138.73 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Cardiac 0 1,579 1.78 0.00 (0 - 1.68) Same Cardiothoracic 6 5,503 6.21 0.97 (0.39 - 2.01) Same Medical (major teaching) 6 3,956 4.46 1.34 (0.54 - 2.79) Same Surgical 3 3,931 4.44 0.68 (0.17 - 1.84) Same Neonatal 7 1,727 2.47 2.83 (1.23 - 5.60) Higher

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.8

0.6 Adult

1.0 Hospital

0.4 Neonatal Ratio SIR 0.5 State Utilization 0.2 State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Catheter-Associated Urinary Tract Infection Hospital CAUTI SIRs by ICU Type for 2016 Calendar Year Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation Infections Interval Cardiac 6 2018 3.22 1.86 (0.75 - 3.87) Same Cardiothoracic 5 5905 7.69 0.65 (0.23 - 1.44) Same Medical (major teaching) 1 4137 5.48 0.18 (0.00 - 0.9) Lower Surgical 17 7846 14.32 1.19 (0.71 - 1.86) Same

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.5 0.8 0.75 Adult

1.0 Hospital

0.7 Ratio SIR 0.5 State Utilization Utilization 0.65 State (Adult) 0.0 0.6 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Brigham and Women's Hospital - Boston, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 5 462 4.15 1.21 (0.44 - 2.67) Same Knee Prosthesis (KPRO) 7 642 2.07 3.39 (1.48 - 6.69) Higher Hip Prosthesis (HPRO) 1 559 4.47 0.22 (0.01 - 1.10) Same Abdominal Hysterectomy (HYST) 3 516 4.96 0.60 (0.15 - 1.64) Same Vaginal Hysterectomy (VHYS) 0 70 0.52 0.00 (0 - 5.78) Same Colon Surgery (COLO) 17 738 21.63 0.79 (0.47 - 1.23) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 160 231,021 187.97 0.85 (0.72 - 0.99) Lower Methicillin-resistant Staphylococcus (MRSA) 6 263,531 22.10 0.27 (0.11 - 0.56) Lower aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Holyoke Medical Center - Holyoke, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Undergraduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 198 Number of ICU Beds 10 80% Medical contraindication 92% Number of Admissions 6,355 70% Declined vaccine 77% Number of Patient Days 26,231 60% Vaccine coverage Beds per Infection Preventionist 99.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 983 0.74 0.00 (0 - 4.04) Same (not major teaching)

1.0Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 0.8 0.6 Adult 0.5 Hospital

0.4 Ratio SIR State

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Holyoke Medical Center - Holyoke, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 110 0.32 Not calculable Hip Prosthesis (HPRO) 1 77 0.37 Not calculable Abdominal Hysterectomy (HYST) 0 5 0.02 Not calculable Vaginal Hysterectomy (VHYS) 0 5 0.02 Not calculable Colon Surgery (COLO) 0 52 1.11 0.00 (0 - 2.70) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 1 22,242 9.69 0.10 (0.00 - 0.50) Lower Methicillin-resistant Staphylococcus (MRSA) 0 23,468 0.93 0.00 (0 - 3.21) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - St. Elizabeth's Medical Center - Brighton, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status For-profit 90% Unknown status Number of Beds 287 Medical contraindication Number of ICU Beds 46 80% 92% Number of Admissions 11,028 70% 91% Declined vaccine Number of Patient Days 60,053 60% Vaccine coverage Beds per Infection Preventionist 287.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 5 5,266 5.94 0.84 (0.30 - 1.86) Same (major teaching) Neonatal 2 292 0.46 Not calculable

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 1

Adult

1.0 Hospital

0.5 Neonatal Ratio SIR 0.5 State Utilization State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 1 1.5 Adult

Hospital

1.0 0.5 Ratio SIR State

0.5 Utilization State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - St. Elizabeth's Medical Center - Brighton, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 1 431 2.76 0.36 (0.01 - 1.78) Same Knee Prosthesis (KPRO) 2 96 0.34 Not calculable Hip Prosthesis (HPRO) 0 98 0.60 0.00 (0 - 5.00) Same Abdominal Hysterectomy (HYST) 0 135 0.85 0.00 (0 - 3.54) Same Vaginal Hysterectomy (VHYS) 1 44 0.33 Not calculable Colon Surgery (COLO) 2 93 2.46 0.81 (0.13 - 2.68) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 45 44,626 31.02 1.45 (1.07 - 1.92) Higher Methicillin-resistant Staphylococcus (MRSA) 6 51,127 3.93 1.53 (0.61 - 3.17) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Holy Family Hospital - Methuen, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status For-profit 90% Unknown status Number of Beds 261 Medical contraindication Number of ICU Beds 19 80% 92% Number of Admissions 10,033 70% 89% Declined vaccine Number of Patient Days 45,110 60% Vaccine coverage Beds per Infection Preventionist 261.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 1,173 1.02 0.00 (0 - 2.94) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

0.4

0.5 Hospital Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Holy Family Hospital - Methuen, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 286 0.77 0.00 (0 - 3.90) Same Hip Prosthesis (HPRO) 0 236 0.97 0.00 (0 - 3.09) Same Abdominal Hysterectomy (HYST) 0 50 0.33 Not calculable Vaginal Hysterectomy (VHYS) 0 6 0.03 Not calculable Colon Surgery (COLO) 0 112 2.24 0.00 (0 - 1.33) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 32 40,892 28.60 1.12 (0.77 - 1.56) Same Methicillin-resistant Staphylococcus (MRSA) 1 44,823 2.00 0.50 (0.02 - 2.46) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Carney Hospital - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status For-profit 90% Unknown status Number of Beds 110 Medical contraindication Number of ICU Beds 10 80% 92% Number of Admissions 4,890 70% 91% Declined vaccine Number of Patient Days 27,918 60% Vaccine coverage Beds per Infection Preventionist 110.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 1 908 0.79 1.26 (0.06 - 6.21) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 2.0 0.45 1.5 Adult Hospital

1.0 0.4 Ratio SIR State

0.5 Utilization State (Adult) 0.0 0.35 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.62 1.5 0.6 Adult

Hospital

1.0 0.58 Ratio SIR State

0.5 Utilization 0.56 State (Adult) 0.0 0.54 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Carney Hospital - Boston, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 1 87 0.27 Not calculable Hip Prosthesis (HPRO) 0 27 0.10 Not calculable Abdominal Hysterectomy (HYST) 1 30 0.14 Not calculable Vaginal Hysterectomy (VHYS) 0 2 0.01 Not calculable Colon Surgery (COLO) 0 48 1.02 0.00 (0 - 2.94) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 10 12,684 11.56 0.87 (0.43 - 1.54) Same Methicillin-resistant Staphylococcus (MRSA) 2 12,684 0.65 3.06 (0.51 - 10.10) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Newton-Wellesley Hospital - Newton, MA

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 0.5 0.6 Adult

Hospital 0.4

0.3 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Newton-Wellesley Hospital - Newton, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 1 457 1.41 0.71 (0.03 - 3.50) Same Hip Prosthesis (HPRO) 4 585 2.38 1.68 (0.53 - 4.05) Same Abdominal Hysterectomy (HYST) 0 68 0.41 Not calculable Vaginal Hysterectomy (VHYS) 0 42 0.31 Not calculable Colon Surgery (COLO) 1 130 2.54 0.39 (0.02 - 1.94) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 19 59,851 44.96 0.42 (0.26 - 0.64) Lower Methicillin-resistant Staphylococcus (MRSA) 1 61,870 2.77 0.36 (0.01 - 1.78) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Morton Hospital - Taunton, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status For-profit 90% Unknown status Number of Beds 133 Medical contraindication Number of ICU Beds 12 80% 92% Number of Admissions 5,555 70% 92% Declined vaccine Number of Patient Days 23,233 60% Vaccine coverage Beds per Infection Preventionist 133.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 1 802 0.60 1.66 (0.08 - 8.16) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 4.0 0.6 3.0 Adult Hospital 0.4

2.0 Ratio SIR State 0.2

1.0 Utilization State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 3.0 0.8 0.6 Adult 2.0 Hospital

0.4 Ratio SIR 1.0 State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Morton Hospital - Taunton, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 3 139 0.62 4.88 (1.24 - 13.27) Higher Hip Prosthesis (HPRO) 2 51 0.32 Not calculable Abdominal Hysterectomy (HYST) 0 15 0.07 Not calculable Vaginal Hysterectomy (VHYS) 0 10 0.04 Not calculable Colon Surgery (COLO) 0 62 1.25 0.00 (0 - 2.38) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 21 19,709 18.41 1.14 (0.72 - 1.71) Same Methicillin-resistant Staphylococcus (MRSA) 2 20,920 0.81 2.46 (0.41 - 8.13) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care Good Samaritan Medical Center - Brockton, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status For-profit 90% Unknown status Number of Beds 267 Medical contraindication Number of ICU Beds 18 80% 92% 92% Number of Admissions 17,065 70% Declined vaccine Number of Patient Days 74,090 60% Vaccine coverage Beds per Infection Preventionist 152.57 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 1 1,576 1.37 0.73 (0.03 - 3.60) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.5 1 2.0 Adult

1.5 Hospital

0.5 Ratio SIR 1.0 State 0.5 Utilization State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care Good Samaritan Medical Center - Brockton, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 1 260 0.62 1.62 (0.08 - 8.00) Same Hip Prosthesis (HPRO) 3 182 0.82 3.67 (0.93 - 9.97) Same Abdominal Hysterectomy (HYST) 0 44 0.25 Not calculable Vaginal Hysterectomy (VHYS) 0 66 0.28 Not calculable Colon Surgery (COLO) 1 150 2.80 0.36 (0.01 - 1.76) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 43 52,550 39.04 1.10 (0.80 - 1.47) Same Methicillin-resistant Staphylococcus (MRSA) 8 56,613 2.22 3.60 (1.67 - 6.83) Higher aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Boston Medical Center - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 487 Medical contraindication Number of ICU Beds 89 80% 92% 96% Number of Admissions 36,953 70% Declined vaccine Number of Patient Days 142,919 60% Vaccine coverage Beds per Infection Preventionist 121.75 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical (major teaching) 6 4,809 5.43 1.11 (0.44 - 2.3) Same Pediatric 1 118 0.17 Not calculable Surgical 3 2,772 3.13 0.96 (0.24 - 2.61) Same Trauma 2 1,374 2.10 0.95 (0.16 - 3.14) Same Neonatal 1 931 1.71 0.58 (0.02 - 2.87) Same

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.6

Adult

1.0 Hospital 0.4 Pediatric Ratio SIR 0.5 State 0.2 Neonatal Utilization State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Catheter-Associated Urinary Tract Infection Hospital CAUTI SIRs by ICU Type for 2016 Calendar Year Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation Infections Interval Medical (major teaching) 5 3769 5.00 1.00 (0.36 - 2.21) Same Pediatric 0 80 0.14 Not calculable Surgical 5 2552 4.66 1.07 (0.39 - 2.37) Same Trauma 8 1615 4.43 1.81 (0.83 - 3.43) Same

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.5 0.8

Adult 2.0 0.6

1.5 Hospital

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Boston Medical Center - Boston, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 0 80 0.85 0.00 (0 - 3.51) Same Knee Prosthesis (KPRO) 3 197 0.61 4.88 (1.24 - 13.27) Higher Hip Prosthesis (HPRO) 4 145 1.02 3.90 (1.24 - 9.41) Higher Abdominal Hysterectomy (HYST) 1 161 1.51 0.66 (0.03 - 3.27) Same Vaginal Hysterectomy (VHYS) 1 61 0.45 Not calculable Colon Surgery (COLO) 3 200 6.75 0.44 (0.11 - 1.21) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 97 133,934 96.74 1.00 (0.81 - 1.21) Same Methicillin-resistant Staphylococcus (MRSA) 6 146,012 10.04 0.60 (0.24 - 1.24) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Beth Israel Deaconess Hospital - Plymouth - Plymouth, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Undergraduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 150 Medical contraindication Number of ICU Beds 13 80% 92% 97% Number of Admissions 10,170 70% Declined vaccine Number of Patient Days 45,269 60% Vaccine coverage Beds per Infection Preventionist 107.14 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 1 1,275 0.96 1.04 (0.05 - 5.13) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.4 Adult

1.0 Hospital 0.38 Ratio SIR 0.5 State 0.36

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.62 1.5 0.6 Adult

Hospital

1.0 0.58 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Beth Israel Deaconess Hospital - Plymouth - Plymouth, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 323 0.73 0.00 (0 - 4.13) Same Hip Prosthesis (HPRO) 0 192 0.70 0.00 (0 - 4.26) Same Abdominal Hysterectomy (HYST) 0 23 0.10 Not calculable Vaginal Hysterectomy (VHYS) 0 39 0.16 Not calculable Colon Surgery (COLO) 1 87 1.99 0.50 (0.02 - 2.48) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 25 35,886 30.81 0.81 (0.53 - 1.18) Same Methicillin-resistant Staphylococcus (MRSA) 1 39,257 1.54 0.65 (0.03 - 3.19) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lahey Health - Winchester Hospital - Winchester, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 189 Medical contraindication Number of ICU Beds 10 80% 92% 97% Number of Admissions 13,009 70% Declined vaccine Number of Patient Days 49,144 60% Vaccine coverage Beds per Infection Preventionist 94.50 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 658 0.58 0.00 (0 - 5.20) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.65 1.5 Adult 0.6 Hospital

1.0 Ratio SIR State 0.55

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lahey Health - Winchester Hospital - Winchester, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 4 416 1.23 3.26 (1.03 - 7.85) Higher Hip Prosthesis (HPRO) 0 255 0.93 0.00 (0 - 3.23) Same Abdominal Hysterectomy (HYST) 1 42 0.24 Not calculable Vaginal Hysterectomy (VHYS) 0 8 0.03 Not calculable Colon Surgery (COLO) 2 97 2.03 0.99 (0.16 - 3.25) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 21 47,200 37.42 0.56 (0.35 - 0.84) Lower Methicillin-resistant Staphylococcus (MRSA) 0 56,116 2.03 0.00 (0 - 1.47) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Emerson Hospital - Concord, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 179 Medical contraindication Number of ICU Beds 14 80% 92% 94% Number of Admissions 9,487 70% Declined vaccine Number of Patient Days 31,690 60% Vaccine coverage Beds per Infection Preventionist 179.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 1,072 0.81 0.00 (0 - 3.70) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.6 Adult

1.0 Hospital 0.4 Ratio SIR 0.5 State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 3.0 0.65 Adult 2.0 0.6

Hospital Ratio SIR 1.0 State 0.55

Utilization State (Adult) 0.0 0.5 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Emerson Hospital - Concord, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 1 250 0.72 1.40 (0.07 - 6.89) Same Hip Prosthesis (HPRO) 0 147 0.73 0.00 (0 - 4.08) Same Abdominal Hysterectomy (HYST) 0 8 0.06 Not calculable Vaginal Hysterectomy (VHYS) 0 12 0.05 Not calculable Colon Surgery (COLO) 0 57 1.07 0.00 (0 - 2.79) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 12 24,691 17.06 0.70 (0.38 - 1.19) Same Methicillin-resistant Staphylococcus (MRSA) 1 28,885 0.96 1.04 (0.05 - 5.12) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lowell General Hospital - Main Campus - Lowell, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 176 Medical contraindication Number of ICU Beds 11 80% 92% 98% Number of Admissions 17,445 70% Declined vaccine Number of Patient Days 67,844 60% Vaccine coverage Beds per Infection Preventionist 58.67 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 2 2,097 1.58 1.27 (0.21 - 4.18) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.8 0.6 Adult

1.0 Hospital

0.4 Ratio SIR 0.5 State

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lowell General Hospital - Main Campus - Lowell, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 1 636 1.96 0.51 (0.02 - 2.52) Same Hip Prosthesis (HPRO) 3 334 1.69 1.78 (0.45 - 4.83) Same Abdominal Hysterectomy (HYST) 1 29 0.16 Not calculable Vaginal Hysterectomy (VHYS) 0 5 0.02 Not calculable Colon Surgery (COLO) 0 144 2.47 0.00 (0 - 1.21) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 14 67,138 24.43 0.57 (0.32 - 0.93) Lower Methicillin-resistant Staphylococcus (MRSA) 2 74,465 2.11 0.95 (0.15 - 3.13) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lahey Health - Lahey Hospital & Medical Center - Burlington, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 345 Medical contraindication Number of ICU Beds 54 80% 92% 98% Number of Admissions 23,895 70% Declined vaccine Number of Patient Days 119,733 60% Vaccine coverage Beds per Infection Preventionist 172.50 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Cardiac 2 1,293 1.46 1.37 (0.23 - 4.53) Same Cardiothoracic 2 1,337 1.51 1.33 (0.22 - 4.38) Same Medical (major teaching) 1 3,849 4.34 0.23 (0.01 - 1.13) Same Surgical 3 3,902 4.40 0.68 (0.17 - 1.85) Same

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.8 0.6 Adult Hospital

0.5 0.4 Ratio SIR State

Catheter-Associated Urinary Tract Infection Hospital CAUTI SIRs by ICU Type for 2016 Calendar Year Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation Infections Interval Cardiac 1 1713 2.74 0.37 (0.01 - 1.80) Same Cardiothoracic 2 1439 1.87 1.07 (0.17 - 3.52) Same Medical (major teaching) 9 4754 6.30 1.43 (0.69 - 2.62) Same Surgical 4 4449 8.12 0.49 (0.15 - 1.18) Same

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.5 1 Adult

1.0 Hospital

0.5 Ratio SIR 0.5 State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lahey Health - Lahey Hospital & Medical Center - Burlington, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 0 329 2.09 0.00 (0 - 1.43) Same Knee Prosthesis (KPRO) 1 515 1.92 0.52 (0.02 - 2.56) Same Hip Prosthesis (HPRO) 4 512 2.89 1.38 (0.44 - 3.33) Same Abdominal Hysterectomy (HYST) 1 171 1.40 0.71 (0.03 - 3.51) Same Vaginal Hysterectomy (VHYS) 0 50 0.37 Not calculable Colon Surgery (COLO) 5 413 10.60 0.47 (0.17 - 1.04) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 143 112,909 87.11 1.64 (1.38 - 1.92) Higher Methicillin-resistant Staphylococcus (MRSA) 3 112,909 7.18 0.42 (0.10 - 1.13) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Anna Jaques Hospital - Newburyport, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 111 Medical contraindication Number of ICU Beds 8 80% 92% 96% Number of Admissions 7,096 70% Declined vaccine Number of Patient Days 27,970 60% Vaccine coverage Beds per Infection Preventionist 123.33 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 356 0.27 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.62 1.5 0.6 Adult

Hospital 0.58

1.0 Ratio SIR State 0.56 0.5 Utilization 0.54 State (Adult) 0.0 0.52 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Anna Jaques Hospital - Newburyport, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 217 0.54 0.00 (0 - 5.51) Same Hip Prosthesis (HPRO) 2 112 0.45 Not calculable Abdominal Hysterectomy (HYST) 0 27 0.15 Not calculable Vaginal Hysterectomy (VHYS) 2 44 0.18 Not calculable Colon Surgery (COLO) 0 51 0.96 0.00 (0 - 3.10) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 13 25,608 15.14 0.86 (0.47 - 1.43) Same Methicillin-resistant Staphylococcus (MRSA) 0 28,074 0.95 0.00 (0 - 3.13) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Heywood Hospital - Gardner, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 134 Medical contraindication Number of ICU Beds 6 80% 92% Number of Admissions 2,480 70% 91% Declined vaccine Number of Patient Days 256,872 60% Vaccine coverage Beds per Infection Preventionist 134.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical 0 296 0.22 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 1 1.5 Adult

Hospital

1.0 0.5 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Heywood Hospital - Gardner, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 87 0.33 Not calculable Hip Prosthesis (HPRO) 0 60 0.29 Not calculable Abdominal Hysterectomy (HYST) 0 11 0.05 Not calculable Vaginal Hysterectomy (VHYS) 0 53 0.22 Not calculable Colon Surgery (COLO) 0 34 0.52 0.00 (0 - 5.71) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 8 17,972 8.06 0.99 (0.46 - 1.88) Same Methicillin-resistant Staphylococcus (MRSA) 0 19,158 0.53 0.00 (0 - 5.67) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Boston Children's Hospital - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 415 Medical contraindication Number of ICU Beds 101 80% 92% 97% Number of Admissions 25,521 70% Declined vaccine Number of Patient Days 118,345 60% Vaccine coverage Beds per Infection Preventionist 83.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Pediatric 36 16,413 27.27 1.32 (0.93 - 1.80) Same Neonatal 9 3,201 3.87 2.32 (1.13 - 4.26) Higher

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.8 0.6 Neonatal 1.0 Hospital

0.4 Ratio SIR 0.5 State

Utilization 0.2 Pediatric 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios

1.0 0.26

Hospital 0.24

0.5 Pediatric Ratio

SIR State 0.22 Utilization

0.0 0.2 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Boston Children's Hospital - Boston, MA

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 COLO *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 74 119,555 55.73 1.33 (1.05 - 1.65) Higher Methicillin-resistant Staphylococcus (MRSA) 6 128,561 4.10 1.46 (0.59 - 3.04) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 UMass Memorial Health Care - HealthAlliance Hospital - Leominster, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 143 Medical contraindication Number of ICU Beds 10 80% 92% Number of Admissions 7,520 70% 92% Declined vaccine Number of Patient Days 31,452 60% Vaccine coverage Beds per Infection Preventionist 143.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 1,070 0.94 0.00 (0 - 3.20) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.6 Adult

1.0 Hospital 0.4 Ratio SIR 0.5 State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 4.0 0.8 3.0 0.6 Adult

Hospital

2.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 UMass Memorial Health Care - HealthAlliance Hospital - Leominster, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 3 155 0.48 Not calculable Hip Prosthesis (HPRO) 1 83 0.43 Not calculable Abdominal Hysterectomy (HYST) 0 62 0.31 Not calculable Vaginal Hysterectomy (VHYS) 0 1 0.00 Not calculable Colon Surgery (COLO) 0 70 1.49 0.00 (0 - 2.00) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 18 29,104 21.72 0.83 (0.50 - 1.28) Same Methicillin-resistant Staphylococcus (MRSA) 1 31,452 1.49 0.67 (0.03 - 3.31) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Mount Auburn Hospital - Cambridge, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 217 Medical contraindication Number of ICU Beds 20 80% 92% 98% Number of Admissions 20,584 70% Declined vaccine Number of Patient Days 64,316 60% Vaccine coverage Beds per Infection Preventionist 86.80 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical (major teaching) 0 1,137 1.11 0.00 (0 - 2.68) Same Surgical 2 1,633 1.60 1.25 (0.21 - 4.13) Same

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.7 0.65 Adult Hospital

0.5 0.6 Ratio SIR State

Utilization 0.55 State (Adult) 0.0 0.5 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.72 1.5 0.7 Adult

Hospital

1.0 0.68 Ratio SIR State

0.5 Utilization 0.66 State (Adult) 0.0 0.64 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Mount Auburn Hospital - Cambridge, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 0 122 0.93 0.00 (0 - 3.23) Same Knee Prosthesis (KPRO) 1 245 0.82 1.23 (0.06 - 6.05) Same Hip Prosthesis (HPRO) 2 174 1.13 1.77 (0.29 - 5.83) Same Abdominal Hysterectomy (HYST) 2 140 1.02 1.96 (0.32 - 6.46) Same Vaginal Hysterectomy (VHYS) 0 26 0.19 Not calculable Colon Surgery (COLO) 1 71 1.69 0.59 (0.03 - 2.91) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 26 56,724 37.92 0.69 (0.45 - 0.99) Lower Methicillin-resistant Staphylococcus (MRSA) 2 64,316 2.62 0.76 (0.12 - 2.52) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Shriners Hospital for Children - Boston - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 30 Medical contraindication Number of ICU Beds 6 80% 92% 93% Number of Admissions 1,176 70% Declined vaccine Number of Patient Days 3,560 60% Vaccine coverage Beds per Infection Preventionist 30.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Pediatric 2 706 0.81 2.47 (0.41 - 8.15) Same

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 5.0 1

4.0

3.0 Hospital

0.99 Pediatric Ratio SIR 2.0 State 1.0 Utilization 0.0 0.98 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios

1.0 0.48

0.46 Hospital

0.5 Pediatric Ratio

SIR State 0.44 Utilization 0.0 0.42 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Shriners Hospital for Children - Boston - Boston, MA

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 1 3,560 0.64 1.56 (0.07 - 7.69) Same Methicillin-resistant Staphylococcus (MRSA) 0 3,560 0.05 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Noble Hospital - Westfield, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 97 Medical contraindication Number of ICU Beds 6 80% 92% 95% Number of Admissions 2,921 70% Declined vaccine Number of Patient Days 15,788 60% Vaccine coverage Beds per Infection Preventionist 64.67 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 51 0.04 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.7 1.5 0.65 Adult

Hospital

1.0 0.6 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Noble Hospital - Westfield, MA

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 2015 2016 KPRO HPRO COLO *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 1 7,391 3.34 0.30 (0.01 - 1.47) Same Methicillin-resistant Staphylococcus (MRSA) 0 7,391 0.22 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 New England Baptist Hospital - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 118 Medical contraindication Number of ICU Beds 8 80% 92% 96% Number of Admissions 7,974 70% Declined vaccine Number of Patient Days 22,300 60% Vaccine coverage Beds per Infection Preventionist 118.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 1 562 0.49 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 6.0 1 Adult 4.0 Hospital

0.5 Ratio SIR 2.0 State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 New England Baptist Hospital - Boston, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 2 2,959 10.90 0.18 (0.03 - 0.60) Lower Hip Prosthesis (HPRO) 4 2,567 12.42 0.32 (0.10 - 0.77) Lower Colon Surgery (COLO) 0 1 0.04 Not calculable

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 1 22,297 5.65 0.18 (0.00 - 0.87) Lower Methicillin-resistant Staphylococcus (MRSA) 0 22,297 0.51 0.00 (0 - 5.84) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Hallmark Health System - Lawrence Memorial Hospital of Medford - Medford, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 44 Medical contraindication Number of ICU Beds 3 80% 92% 98% Number of Admissions 3,257 70% Declined vaccine Number of Patient Days 14,783 60% Vaccine coverage Beds per Infection Preventionist 73.33 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 255 0.17 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Hallmark Health System - Lawrence Memorial Hospital of Medford - Medford, MA

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 7 7,981 3.90 1.79 (0.78 - 3.54) Same Methicillin-resistant Staphylococcus (MRSA) 0 7,981 0.18 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lowell General Hospital - Saints Campus - Lowell, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 75 Medical contraindication Number of ICU Beds 10 80% 92% 96% Number of Admissions 4,422 70% Declined vaccine Number of Patient Days 19,109 60% Vaccine coverage Beds per Infection Preventionist 25.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 1,060 0.71 0.00 (0 - 4.21) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.8 0.6 Adult

1.0 Hospital

0.4 Ratio SIR 0.5 State

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 4.0 0.8 3.0 0.6 Adult

Hospital

2.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lowell General Hospital - Saints Campus - Lowell, MA

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 KPRO COLO *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 9 21,509 9.13 0.99 (0.48 - 1.80) Same Methicillin-resistant Staphylococcus (MRSA) 0 21,509 0.94 0.00 (0 - 3.18) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 UMass Memorial Health Care - Clinton Hospital - Clinton, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status For-profit 90% Unknown status Number of Beds 41 Medical contraindication Number of ICU Beds 0 80% 92% 92% Number of Admissions 968 70% Declined vaccine Number of Patient Days 8,555 60% Vaccine coverage Beds per Infection Preventionist 41.00 50% State Hospital Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 2 3,514 1.15 1.74 (0.29 - 5.74) Same Methicillin-resistant Staphylococcus (MRSA) 0 3,514 0.08 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Milford Regional Medical Center - Milford, MA

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 0.5 0.6 Adult

Hospital 0.4

0.3 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.0 0.8 0.6 Adult

Hospital

0.5 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Milford Regional Medical Center - Milford, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 118 0.45 Not calculable Hip Prosthesis (HPRO) 1 119 0.82 1.21 (0.06 - 5.98) Same Abdominal Hysterectomy (HYST) 3 51 0.27 Not calculable Vaginal Hysterectomy (VHYS) 1 13 0.10 Not calculable Colon Surgery (COLO) 0 60 1.25 0.00 (0 - 2.39) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 26 32,453 34.38 0.76 (0.50 - 1.09) Same Methicillin-resistant Staphylococcus (MRSA) 1 34,445 1.64 0.61 (0.03 - 3.01) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Baystate Franklin Medical Center - Greenfield, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 90 80% Medical contraindication Number of ICU Beds 6 99% 92% Number of Admissions 5,135 70% Declined vaccine Number of Patient Days 19,774 60% Vaccine coverage Beds per Infection Preventionist 112.50 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 218 0.15 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Baystate Franklin Medical Center - Greenfield, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 65 0.15 Not calculable Hip Prosthesis (HPRO) 1 54 0.25 Not calculable Abdominal Hysterectomy (HYST) 2 23 0.11 Not calculable Vaginal Hysterectomy (VHYS) 0 45 0.19 Not calculable Colon Surgery (COLO) 1 55 1.03 0.98 (0.04 - 4.81) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 5 18,472 8.74 0.57 (0.21 - 1.26) Same Methicillin-resistant Staphylococcus (MRSA) 0 19,774 0.41 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lawrence General Hospital - Lawrence, MA

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.5 0.6 Adult

1.0 Hospital 0.4 Ratio SIR 0.5 State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.5 0.8 2.0 0.6 Adult

1.5 Hospital

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lawrence General Hospital - Lawrence, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 93 0.35 Not calculable Hip Prosthesis (HPRO) 0 71 0.39 Not calculable Abdominal Hysterectomy (HYST) 1 30 0.16 Not calculable Vaginal Hysterectomy (VHYS) 0 8 0.06 Not calculable Colon Surgery (COLO) 1 63 1.43 0.70 (0.03 - 3.46) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 34 45,093 30.18 1.13 (0.79 - 1.55) Same Methicillin-resistant Staphylococcus (MRSA) 1 48,730 2.48 0.40 (0.02 - 1.98) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 South Shore Hospital - South Weymouth, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 434 Medical contraindication Number of ICU Beds 54 80% 92% 97% Number of Admissions 28,734 70% Declined vaccine Number of Patient Days 118,870 60% Vaccine coverage Beds per Infection Preventionist 217.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Cardiac 0 1,167 1.18 0.00 (0 - 2.54) Same Medical/Surgical 0 1,455 1.47 0.00 (0 - 2.04) Same (not major teaching) Surgical 1 1,390 1.40 0.71 (0.03 - 3.52) Same Neonatal 0 310 0.38 Not calculable

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.8

Adult 0.6 Hospital

0.5 0.4 Neonatal Ratio SIR State Utilization 0.2 State (Adult) 0.0 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Catheter-Associated Urinary Tract Infection Hospital CAUTI SIRs by ICU Type for 2016 Calendar Year Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation Infections Interval Cardiac 3 1135 1.42 2.11 (0.53 - 5.74) Same Medical/Surgical 3 1489 1.52 1.97 (0.50 - 5.36) Same (not major teaching) Surgical 4 1582 2.26 1.77 (0.56 - 4.26) Same

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.5 0.7 2.0 0.65 Adult

1.5 Hospital

0.6 Ratio SIR 1.0 State

Utilization Utilization State (Adult) 0.5 0.55 0.0 0.5 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 South Shore Hospital - South Weymouth, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 3 407 1.08 2.77 (0.70 - 7.53) Same Hip Prosthesis (HPRO) 0 296 1.44 0.00 (0 - 2.08) Same Abdominal Hysterectomy (HYST) 3 256 1.44 2.09 (0.53 - 5.68) Same Vaginal Hysterectomy (VHYS) 1 34 0.14 Not calculable Colon Surgery (COLO) 4 220 5.48 0.73 (0.23 - 1.76) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 55 116,152 86.36 0.64 (0.48 - 0.82) Lower Methicillin-resistant Staphylococcus (MRSA) 1 131,750 5.13 0.20 (0.01 - 0.96) Lower aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Martha's Vineyard Hospital - Oak Bluffs, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 25 Medical contraindication Number of ICU Beds 3 80% 92% 95% Number of Admissions 1,222 70% Declined vaccine Number of Patient Days 5,664 60% Vaccine coverage Beds per Infection Preventionist 50.00 50% State Hospital Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 11 0.02 Not calculable Hip Prosthesis (HPRO) 0 16 0.05 Not calculable Abdominal Hysterectomy (HYST) 0 2 0.01 Not calculable

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 2015 2016 KPRO HPRO HYST *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Cooley Dickinson Hospital - Northampton, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Undergraduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 140 Medical contraindication Number of ICU Beds 11 80% 92% 96% Number of Admissions 9,589 70% Declined vaccine Number of Patient Days 32,687 60% Vaccine coverage Beds per Infection Preventionist 100.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 561 0.42 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.45 Adult

Hospital 0.4

0.5 Ratio SIR State 0.35

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 4.0 0.65 3.0 Adult 0.6 Hospital

2.0 Ratio SIR State 0.55

1.0 Utilization State (Adult) 0.0 0.5 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Cooley Dickinson Hospital - Northampton, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 1 201 0.57 1.77 (0.08 - 8.72) Same Hip Prosthesis (HPRO) 1 178 0.79 1.26 (0.06 - 6.20) Same Abdominal Hysterectomy (HYST) 0 65 0.33 Not calculable Vaginal Hysterectomy (VHYS) 1 19 0.08 Not calculable Colon Surgery (COLO) 2 74 1.57 1.27 (0.21 - 4.21) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 30 24,776 18.72 1.60 (1.10 - 2.25) Higher Methicillin-resistant Staphylococcus (MRSA) 0 26,266 1.14 0.00 (0 - 2.61) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Beth Israel Deaconess Hospital - Needham - Needham, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 58 Medical contraindication Number of ICU Beds 7 80% 92% 98% Number of Admissions 4,330 70% Declined vaccine Number of Patient Days 9,497 60% Vaccine coverage Beds per Infection Preventionist 58.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 407 0.27 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 4.0 0.8 3.0 0.6 Adult

Hospital

2.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Beth Israel Deaconess Hospital - Needham - Needham, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 36 0.13 Not calculable Hip Prosthesis (HPRO) 0 49 0.28 Not calculable Abdominal Hysterectomy (HYST) 0 1 0.01 Not calculable Colon Surgery (COLO) 1 28 0.49 Not calculable

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 2015 2016 2015 2016 KPRO HPRO HYST COLO *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 10 14,142 8.31 1.20 (0.61 - 2.14) Same Methicillin-resistant Staphylococcus (MRSA) 0 14,142 0.58 0.00 (0 - 5.17) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 UMass Memorial Health Care - Marlborough Hospital - Marlborough, MA

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 0.5 0.6 Adult

Hospital 0.4

0.3 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.5 0.7 0.65 Adult 1.0 Hospital

0.6 Ratio SIR 0.5 State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 UMass Memorial Health Care - Marlborough Hospital - Marlborough, MA

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 19 19,048 11.26 1.69 (1.04 - 2.58) Higher Methicillin-resistant Staphylococcus (MRSA) 1 19,048 0.90 1.12 (0.05 - 5.50) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Brigham and Women's - Faulkner Hospital - Boston, MA

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 2.0 0.6 1.5 Adult Hospital 0.4

1.0 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.0 0.8 0.6 Adult

Hospital

0.5 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Brigham and Women's - Faulkner Hospital - Boston, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 3 491 1.21 2.48 (0.63 - 6.75) Same Hip Prosthesis (HPRO) 1 239 0.88 1.14 (0.05 - 5.59) Same Abdominal Hysterectomy (HYST) 0 31 0.14 Not calculable Vaginal Hysterectomy (VHYS) 0 14 0.10 Not calculable Colon Surgery (COLO) 1 51 1.06 0.95 (0.04 - 4.66) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 23 34,845 19.77 1.16 (0.75 - 1.71) Same Methicillin-resistant Staphylococcus (MRSA) 1 34,845 1.14 0.88 (0.04 - 4.34) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Beth Israel Deaconess Medical Center - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 746 Medical contraindication Number of ICU Beds 124 80% 92% 93% Number of Admissions 45,834 70% Declined vaccine Number of Patient Days 231,853 60% Vaccine coverage Beds per Infection Preventionist 149.20 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Cardiac 2 1,605 1.81 1.10 (0.18 - 3.64) Same Cardiothoracic 3 3,210 3.62 0.83 (0.21 - 2.25) Same Medical (major teaching) 5 3,530 3.98 1.26 (0.46 - 2.78) Same Medical/Surgical 2 2,021 2.28 0.88 (0.14 - 2.89) Same (major teaching) Neurosurgical 0 654 0.74 0.00 (0 - 4.06) Same Surgical 1 1,959 2.21 0.45 (0.02 - 2.23) Same Trauma 1 1,562 2.39 0.42 (0.02 - 2.06) Same Neonatal 0 1,743 2.60 0.00 (0 - 1.15) Same

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.8

Adult 0.6

Hospital

Catheter-Associated Urinary Tract Infection Hospital CAUTI SIRs by ICU Type for 2016 Calendar Year Predicted Confidence ICU Type Infections Catheter Days SIR Interpretation Infections Interval Cardiac 3 1629 2.60 1.15 (0.29 - 3.13) Same Cardiothoracic 4 3061 3.99 1.00 (0.31 - 2.42) Same Medical (major teaching) 6 3767 4.99 1.20 (0.48 - 2.5) Same Medical/Surgical 2 2119 2.76 0.73 (0.12 - 2.39) Same (major teaching) Neurosurgical 8 929 3.29 2.43 (1.12 - 4.61) Higher Surgical 7 2575 4.70 1.49 (0.65 - 2.94) Same Trauma 12 2174 5.96 2.01 (1.09 - 3.42) Higher

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.75 1.5 Adult 0.7 Hospital

1.0 Ratio SIR State 0.65

0.5 Utilization State (Adult) 0.0 0.6 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Beth Israel Deaconess Medical Center - Boston, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 2 568 3.79 0.53 (0.08 - 1.74) Same Knee Prosthesis (KPRO) 5 425 1.77 2.83 (1.03 - 6.26) Higher Hip Prosthesis (HPRO) 6 390 3.30 1.82 (0.73 - 3.78) Same Abdominal Hysterectomy (HYST) 4 281 2.53 1.58 (0.50 - 3.80) Same Vaginal Hysterectomy (VHYS) 1 61 0.45 Not calculable Colon Surgery (COLO) 21 574 14.48 1.45 (0.92 - 2.17) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 193 198,492 170.46 1.13 (0.98 - 1.30) Same Methicillin-resistant Staphylococcus (MRSA) 14 226,585 15.29 0.92 (0.52 - 1.5) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Harrington Memorial Hospital - Southbridge, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Undergraduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 114 Medical contraindication Number of ICU Beds 6 80% 92% Number of Admissions 1,041 70% 86% Declined vaccine Number of Patient Days 4,429 60% Vaccine coverage Beds per Infection Preventionist 114.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 311 0.23 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Harrington Memorial Hospital - Southbridge, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 74 0.22 Not calculable Hip Prosthesis (HPRO) 0 40 0.18 Not calculable Abdominal Hysterectomy (HYST) 0 5 0.02 Not calculable Vaginal Hysterectomy (VHYS) 0 6 0.03 Not calculable Colon Surgery (COLO) 0 27 0.50 0.00 (0 - 5.95) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 8 16,234 8.84 0.91 (0.42 - 1.71) Same Methicillin-resistant Staphylococcus (MRSA) 0 16,780 0.52 0.00 (0 - 5.80) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Baystate Mary Lane Hospital - Ware, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 25 Medical contraindication Number of ICU Beds 4 80% 92% 96% Number of Admissions 493 70% Declined vaccine Number of Patient Days 1,308 60% Vaccine coverage Beds per Infection Preventionist 125.00 50% State Hospital Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 14 0.04 Not calculable Hip Prosthesis (HPRO) 0 9 0.04 Not calculable Abdominal Hysterectomy (HYST) 0 14 0.08 Not calculable Colon Surgery (COLO) 0 1 0.01 Not calculable

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 0 1,268 0.36 Not calculable Methicillin-resistant Staphylococcus (MRSA) 0 1,268 0.03 aureus Not calculable

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Mercy Medical Center - Springfield, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Undergraduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 251 Number of ICU Beds 16 80% Medical contraindication 70% 92% Number of Admissions 11,937 84% Declined vaccine Number of Patient Days 46,696 60% Vaccine coverage Beds per Infection Preventionist 125.50 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 3 1,246 1.08 2.78 (0.70 - 7.55) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios

10.0 0.5 8.0 0.4 Adult

6.0 Hospital 0.3

SIR 4.0 0.2 State State (Adult) 2.0 0.1

0.0 0 Utilization Ratio Utilization 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios

12.0 0.8 10.0 0.6 Adult 8.0 Hospital 6.0 0.4 SIR 4.0 State 0.2 State (Adult) 2.0

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Mercy Medical Center - Springfield, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 5 0.03 Not calculable Hip Prosthesis (HPRO) 0 17 0.10 Not calculable Abdominal Hysterectomy (HYST) 0 58 0.40 Not calculable Vaginal Hysterectomy (VHYS) 0 17 0.07 Not calculable Colon Surgery (COLO) 4 144 2.90 1.38 (0.43 - 3.32) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 KPRO HPRO HYST VHYS COLO

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 23 43,365 22.33 1.03 (0.66 - 1.52) Same Methicillin-resistant Staphylococcus (MRSA) 3 46,696 1.81 1.66 (0.42 - 4.50) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 CDI MRSA

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Massachusetts Eye and Ear Infirmary - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 41 Medical contraindication Number of ICU Beds 0 80% 70% 92% Number of Admissions 1,202 84% Declined vaccine Number of Patient Days 5,656 60% Vaccine coverage Beds per Infection Preventionist 41.00 50% State Hospital Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 2 6,468 1.33 1.51 (0.25 - 4.97) Same Methicillin-resistant Staphylococcus (MRSA) 0 6,468 0.14 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 North Shore Medical Center - Salem Hospital - Salem, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 271 Number of ICU Beds 40 80% Medical contraindication 92% 94% Number of Admissions 14,578 70% Declined vaccine Number of Patient Days 74,159 60% Vaccine coverage Beds per Infection Preventionist 90.33 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Cardiothoracic 0 329 0.37 Not calculable Medical/Surgical 0 2,609 2.94 0.00 (0 - 1.01) Same (major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios

1.0 0.52

Hospital 0.5 Adult 0.5 SIR State (Adult) State 0.48

0.0 0.46 Utilization Ratio Utilization 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios

1.5 0.8 0.6

1.0 Hospital Adult

0.4 SIR 0.5 State State (Adult) 0.2

0.0 Ratio Utilization 0 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 North Shore Medical Center - Salem Hospital - Salem, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 0 49 0.40 Not calculable Knee Prosthesis (KPRO) 0 219 0.69 0.00 (0 - 4.31) Same Hip Prosthesis (HPRO) 2 237 1.38 1.45 (0.24 - 4.77) Same Abdominal Hysterectomy (HYST) 0 67 0.42 Not calculable Vaginal Hysterectomy (VHYS) 0 52 0.38 Not calculable Colon Surgery (COLO) 4 129 3.36 1.19 (0.37 - 2.87) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 CABG KPRO HPRO HYST VHYS COLO

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 60 60,140 53.35 1.13 (0.86 - 1.43) Same Methicillin-resistant Staphylococcus (MRSA) 2 65,241 3.86 0.52 (0.08 - 1.71) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 CDI MRSA

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Sturdy Memorial Hospital - Attleboro, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 128 Number of ICU Beds 14 80% Medical contraindication 92% 95% Number of Admissions 8,000 70% Declined vaccine Number of Patient Days 29,441 60% Vaccine coverage Beds per Infection Preventionist 128.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical 1 971 0.73 1.37 (0.06 - 6.74) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios

1.5 0.5 0.4

1.0 Hospital 0.3 Adult

SIR 0.2 0.5 State State (Adult) 0.1

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios

2.0 0.75 1.5 0.7 Hospital Adult 1.0 SIR State 0.65 State (Adult) 0.5

0.0 0.6 Utilization Ratio Utilization 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Sturdy Memorial Hospital - Attleboro, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 2 196 0.51 3.95 (0.66 - 13.05) Same Hip Prosthesis (HPRO) 2 93 0.43 Not calculable Abdominal Hysterectomy (HYST) 0 133 0.50 0.00 (0 - 5.98) Same Vaginal Hysterectomy (VHYS) 0 36 0.15 Not calculable Colon Surgery (COLO) 1 62 1.16 0.86 (0.04 - 4.25) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 KPRO HPRO HYST VHYS COLO

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 24 31,072 21.47 1.12 (0.73 - 1.63) Same Methicillin-resistant Staphylococcus (MRSA) 2 33,545 1.11 1.80 (0.30 - 5.93) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 CDI MRSA

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Berkshire Health Systems - Fairview Hospital - Great Barrington, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 25 Number of ICU Beds 4 80% Medical contraindication 92% 98% Number of Admissions 841 70% Declined vaccine Number of Patient Days 3,470 60% Vaccine coverage Beds per Infection Preventionist 25.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 50 0.01 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios

1.0 0.5 0.4

Hospital 0.3 Adult 0.5 SIR State 0.2 State (Adult) 0.1

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios

2.0 0.8 1.5 0.6

Hospital Adult 1.0 0.4 SIR State State (Adult) 0.5 0.2

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Berkshire Health Systems - Fairview Hospital - Great Barrington, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 29 0.06 Not calculable Hip Prosthesis (HPRO) 0 25 0.09 Not calculable Abdominal Hysterectomy (HYST) 0 3 0.02 Not calculable Vaginal Hysterectomy (VHYS) 0 2 0.01 Not calculable Colon Surgery (COLO) 0 6 0.09 Not calculable

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 KPRO HPRO HYST VHYS COLO

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 2 3,470 0.77 2.61 (0.43 - 8.62) Same Methicillin-resistant Staphylococcus (MRSA) 0 3,470 0.07 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 CDI MRSA

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 MetroWest Medical Center - Framingham Union Hospital - Framingham, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status For-profit 90% Unknown status Number of Beds 191 Number of ICU Beds 14 80% Medical contraindication 92% 95% Number of Admissions 6,362 70% Declined vaccine Number of Patient Days 23,690 60% Vaccine coverage Beds per Infection Preventionist 191.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 660 0.58 0.00 (0 - 5.18) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios

2.0 0.5 1.5 0.4 Adult Hospital 0.3 1.0 SIR 0.2 State State (Adult) 0.5 0.1

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios

4.0 0.65 3.0 0.6 Adult Hospital 2.0 SIR State 0.55 State (Adult) 1.0

0.0 0.5 Utilization Ratio Utilization 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 MetroWest Medical Center - Framingham Union Hospital - Framingham, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Abdominal Hysterectomy (HYST) 0 15 0.10 Not calculable Vaginal Hysterectomy (VHYS) 0 2 0.01 Not calculable Colon Surgery (COLO) 2 45 0.99 2.01 (0.33 - 6.64) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 2015 2016 HYST VHYS COLO

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 23 23,492 18.19 1.26 (0.82 - 1.86) Same Methicillin-resistant Staphylococcus (MRSA) 3 27,271 1.22 2.46 (0.62 - 6.69) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 CDI MRSA

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Nantucket Cottage Hospital - Nantucket, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 19 Medical contraindication Number of ICU Beds 0 80% 92% 96% Number of Admissions 949 70% Declined vaccine Number of Patient Days 2,759 60% Vaccine coverage Beds per Infection Preventionist 19.00 50% State Hospital Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 0 2,621 0.45 Not calculable Methicillin-resistant Staphylococcus (MRSA) 0 2,621 0.05 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Cambridge Health Alliance - Cambridge Hospital - Cambridge, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 145 Number of ICU Beds 8 80% Medical contraindication 92% 96% Number of Admissions 6,640 70% Declined vaccine Number of Patient Days 31,101 60% Vaccine coverage Beds per Infection Preventionist 145.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 1 443 0.39 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios

1.0 0.4 0.38 Adult

Hospital 0.36 0.5 SIR 0.34 State State (Adult) 0.32

0.0 0.3 Utilization Ratio Utilization 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios

4.0 0.65 3.0 Adult 0.6 Hospital 2.0 SIR State 0.55 1.0 State (Adult)

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Cambridge Health Alliance - Cambridge Hospital - Cambridge, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 54 0.19 Not calculable Hip Prosthesis (HPRO) 0 46 0.32 Not calculable Abdominal Hysterectomy (HYST) 1 35 0.25 Not calculable Vaginal Hysterectomy (VHYS) 0 15 0.06 Not calculable Colon Surgery (COLO) 1 29 0.78 1.28 (0.06 - 6.30) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 KPRO HPRO HYST VHYS COLO

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 8 28,784 17.38 0.46 (0.21 - 0.87) Lower Methicillin-resistant Staphylococcus (MRSA) 0 31,198 1.46 0.00 (0 - 2.05) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 CDI MRSA

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Cambridge Health Alliance - Everett Hospital - Everett, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 96 Number of ICU Beds 8 80% Medical contraindication 92% 96% Number of Admissions 4,059 70% Declined vaccine Number of Patient Days 26,472 60% Vaccine coverage Beds per Infection Preventionist 96.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 717 0.63 0.00 (0 - 4.77) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios

1.0 0.5 0.4

Hospital 0.3 Adult 0.5 SIR State 0.2 State (Adult) 0.1

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios

3.0 0.7 0.65 Adult 2.0 Hospital 0.6 SIR 1.0 State 0.55 State (Adult)

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Cambridge Health Alliance - Everett Hospital - Everett, MA

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 COLO

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 9 26,629 15.04 0.60 (0.29 - 1.09) Same Methicillin-resistant Staphylococcus (MRSA) 0 26,629 1.71 0.00 (0 - 1.75) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower than Predicted

2015 2016 2015 2016 CDI MRSA

*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Beth Israel Deaconess Hospital - Milton - Milton, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 88 Medical contraindication Number of ICU Beds 8 80% 92% 98% Number of Admissions 5,016 70% Declined vaccine Number of Patient Days 24,362 60% Vaccine coverage Beds per Infection Preventionist 88.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 1 810 0.54 1.84 (0.09 - 9.07) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 2.0 0.6 1.5 Adult Hospital 0.4

1.0 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Beth Israel Deaconess Hospital - Milton - Milton, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 1 436 0.78 1.29 (0.06 - 6.35) Same Hip Prosthesis (HPRO) 0 305 0.98 0.00 (0 - 3.05) Same Abdominal Hysterectomy (HYST) 0 16 0.08 Not calculable Vaginal Hysterectomy (VHYS) 0 3 0.01 Not calculable Colon Surgery (COLO) 2 71 1.15 1.75 (0.29 - 5.76) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 12 22,351 18.45 0.65 (0.35 - 1.10) Same Methicillin-resistant Staphylococcus (MRSA) 0 22,351 0.96 0.00 (0 - 3.12) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Athol Memorial Hospital - Athol, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 25 Medical contraindication Number of ICU Beds 0 80% 92% 96% Number of Admissions 583 70% Declined vaccine Number of Patient Days 3,774 60% Vaccine coverage Beds per Infection Preventionist 62.50 50% State Hospital Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 3 4,260 1.93 1.55 (0.39 - 4.22) Same Methicillin-resistant Staphylococcus (MRSA) 0 4,260 0.09 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Nashoba Valley Medical Center - Ayer, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status For-profit 90% Unknown status Number of Beds 77 Medical contraindication Number of ICU Beds 6 80% 92% 92% Number of Admissions 1,921 70% Declined vaccine Number of Patient Days 11,208 60% Vaccine coverage Beds per Infection Preventionist 128.33 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 208 0.14 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Nashoba Valley Medical Center - Ayer, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 37 0.16 Not calculable Hip Prosthesis (HPRO) 1 29 0.18 Not calculable Abdominal Hysterectomy (HYST) 0 1 0.01 Not calculable Vaginal Hysterectomy (VHYS) 0 1 0.00 Not calculable Colon Surgery (COLO) 0 5 0.09 Not calculable

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 7 5,052 6.78 1.03 (0.45 - 2.04) Same Methicillin-resistant Staphylococcus (MRSA) 0 5,052 0.17 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Hallmark Health System - Melrose-Wakefield Hospital - Melrose, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 126 Medical contraindication Number of ICU Beds 7 80% 92% 98% Number of Admissions 11,509 70% Declined vaccine Number of Patient Days 39,728 60% Vaccine coverage Beds per Infection Preventionist 126.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 695 0.52 0.00 (0 - 5.72) Same (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 2.0 0.6 1.5 Adult Hospital 0.4

1.0 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Hallmark Health System - Melrose-Wakefield Hospital - Melrose, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 2 180 0.54 3.67 (0.61 - 12.12) Same Hip Prosthesis (HPRO) 0 145 0.65 0.00 (0 - 4.61) Same Abdominal Hysterectomy (HYST) 1 51 0.24 Not calculable Vaginal Hysterectomy (VHYS) 1 25 0.11 Not calculable Colon Surgery (COLO) 4 80 1.55 2.58 (0.81 - 6.21) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 30 33,560 18.27 1.64 (1.12 - 2.31) Higher Methicillin-resistant Staphylococcus (MRSA) 0 37,471 1.31 0.00 (0 - 2.29) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Holy Family Hospital at Merrimack Valley - Haverhill, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status For-profit 90% Unknown status Number of Beds 124 Medical contraindication Number of ICU Beds 10 80% 92% Number of Admissions 3,085 70% 89% Declined vaccine Number of Patient Days 17,036 60% Vaccine coverage Beds per Infection Preventionist 124.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 337 0.25 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.7 1.5 0.65 Adult

Hospital

1.0 0.6 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Steward Health Care - Holy Family Hospital at Merrimack Valley - Haverhill, MA

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 9 7,763 7.86 1.15 (0.55 - 2.1) Same Methicillin-resistant Staphylococcus (MRSA) 0 7,763 0.35 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 MetroWest Medical Center - Leonard Morse Hospital - Natick, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Graduate teaching 100% Profit Status For-profit 90% Unknown status Number of Beds 160 Medical contraindication Number of ICU Beds 10 80% 92% 95% Number of Admissions 4,387 70% Declined vaccine Number of Patient Days 31,623 60% Vaccine coverage Beds per Infection Preventionist 160.00 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 0 166 0.15 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 3.0 0.65 0.6 Adult 2.0 Hospital

0.55 Ratio SIR 1.0 State

Utilization 0.5 State (Adult) 0.0 0.45 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 MetroWest Medical Center - Leonard Morse Hospital - Natick, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 118 0.38 Not calculable Hip Prosthesis (HPRO) 1 123 0.67 1.49 (0.07 - 7.34) Same Colon Surgery (COLO) 0 12 0.25 Not calculable

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 8 11,125 8.68 0.92 (0.42 - 1.75) Same Methicillin-resistant Staphylococcus (MRSA) 0 11,125 0.48 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Saint Vincent Hospital - Worcester, MA

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 0.5 0.56 0.54 Adult Hospital

0.3 0.52 Ratio SIR State

Utilization 0.5 State (Adult) 0.0 0.48 2015 2016 2015 2016 *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.0 1 Adult

Hospital

0.5 0.5 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Saint Vincent Hospital - Worcester, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Coronary Artery Bypass Graft (CABG) 1 109 0.66 1.52 (0.07 - 7.48) Same Knee Prosthesis (KPRO) 1 509 2.11 0.47 (0.02 - 2.33) Same Hip Prosthesis (HPRO) 1 504 2.97 0.34 (0.01 - 1.66) Same Abdominal Hysterectomy (HYST) 0 57 0.43 Not calculable Vaginal Hysterectomy (VHYS) 0 13 0.10 Not calculable Colon Surgery (COLO) 0 124 2.69 0.00 (0 - 1.11) Same

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 75 80,708 65.34 1.15 (0.90 - 1.43) Same Methicillin-resistant Staphylococcus (MRSA) 4 86,938 4.55 0.88 (0.27 - 2.11) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Baystate Wing Hospital - Palmer, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 74 Medical contraindication Number of ICU Beds 6 80% 92% 96% Number of Admissions 2,937 70% Declined vaccine Number of Patient Days 15,997 60% Vaccine coverage Beds per Infection Preventionist 46.25 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical/Surgical 1 269 0.18 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 2.0 0.8 1.5 0.6 Adult

Hospital

1.0 0.4 Ratio SIR State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Baystate Wing Hospital - Palmer, MA

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 6 10,815 6.03 1.00 (0.40 - 2.07) Same Methicillin-resistant Staphylococcus (MRSA) 0 10,414 0.24 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lahey Health - Addison Gilbert Hospital - Gloucester, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation No State v. Hospital, 2016-2017 Season Hospital Type Nonteaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 79 Medical contraindication Number of ICU Beds 8 80% 92% 94% Number of Admissions 2,370 70% Declined vaccine Number of Patient Days 9,256 60% Vaccine coverage Beds per Infection Preventionist 39.50 50% State Hospital Central Line-Associated Blood Stream Infection Hospital CLABSI SIRs by ICU Type for 2016 Calendar Year Central Line Predicted Confidence ICU Type Infections SIR Interpretation Days Infections Interval Medical 0 228 0.15 Not calculable (not major teaching)

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 1.0 0.6 Adult

Hospital 0.4

0.5 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.5 0.8 0.6 Adult 1.0 Hospital

0.4 Ratio SIR 0.5 State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Lahey Health - Addison Gilbert Hospital - Gloucester, MA

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 1 12,181 5.46 0.18 (0.00 - 0.90) Lower Methicillin-resistant Staphylococcus (MRSA) 1 12,181 0.43 Not calculable aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 North Shore Medical Center - Union Hospital - Lynn, MA

Hospital & State CLABSI SIRs Compared to National Average Hospital Central Line Utilization Ratios 0.5 0.6 Adult

Hospital 0.4

0.3 Ratio SIR State 0.2

Hospital & State CAUTI SIRs Compared to National Average Hospital Catheter Utilization Ratios 1.5 0.8 0.6 Adult 1.0 Hospital

0.4 Ratio SIR 0.5 State

1 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 North Shore Medical Center - Union Hospital - Lynn, MA

Surgical Site Infection Hospital SSI SIRs by Procedure Type for 2016 Calendar Year Predicted Confidence Procedure Infections Procedures SIR Interpretation Infections Interval Knee Prosthesis (KPRO) 0 267 0.77 0.00 (0 - 3.89) Same Hip Prosthesis (HPRO) 0 92 0.42 Not calculable Abdominal Hysterectomy (HYST) 0 2 0.01 Not calculable Vaginal Hysterectomy (VHYS) 0 2 0.01 Not calculable Colon Surgery (COLO) 0 1 0.02 Not calculable

Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2015 -2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 10 15,606 14.37 0.70 (0.35 - 1.24) Same Methicillin-resistant Staphylococcus (MRSA) 0 15,606 0.85 0.00 (0 - 3.53) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.

2 Massachusetts Calendar Year 2016 HAI Data Summary Release Date: September 2017 Dana-Farber Cancer Institute - Boston, MA

2016 Hospital Survey Statistics HCP Influenza Vaccination Coverage Medical School Affiliation Yes State v. Hospital, 2016-2017 Season Hospital Type Major teaching 100% Profit Status Not-for-profit 90% Unknown status Number of Beds 30 Medical contraindication Number of ICU Beds 0 80% 92% 98% Number of Admissions 810 70% Declined vaccine Number of Patient Days 10,539 60% Vaccine coverage Beds per Infection Preventionist 15.00 50% State Hospital Facility Wide LabID Events Hospital CDI and MRSA SIRs for 2016 Calendar Year Predicted Confidence Event Infections Patient Days SIR Interpretation Infections Interval Clostridium difficile (CDI) 10 10,555 8.44 1.19 (0.60 - 2.11) Same Methicillin-resistant Staphylococcus (MRSA) 0 10,555 0.68 0.00 (0 - 4.40) Same aureus

Statistically Significant Variation from Predicted Number of LabID Events, 2015-2016

Statistically Higher than Predicted

Statistically the Same as Predicted

Statistically Lower

2015 2016 2015 2016 CDI MRSA *Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2016" for more information.