<p>MHA/ONL <em>PatientCareLink </em></p><p>Nursing-Sensitive Measure Report <br>Statistical Appendix <br>April 2016 </p><p>April 2016 </p><p>Statistical Appendix Contents <br> Explanation of Analysis of the Statistical Significance of Hospital Measure <br>Rates </p><p> Acute Care Hospitals Bed-size Group Category Listing  Specialty Hospital Listing  Acute Care Hospitals o NSC-2 Pressure Ulcer Prevalence <br>. Acute Care Hospital Bed-size Group Measure Data Graphs o NSC-3 Patient Falls <br>. Acute Care Hospital Bed-size Group Measure Data Graphs o NSC-4 Falls with Injury <br>. Acute Care Hospital Bed-size Group Measure Data Graphs </p><p> Specialty Hospitals o NSC-2 Pressure Ulcer Prevalence <br>. Rehabilitation Hospitals Group Measure Data Graphs . Long-term Acute Care Hospitals Group Measure Data Graphs o NSC-3 Patient Falls <br>. Rehabilitation Hospitals Group Measure Data Graphs . Long-term Acute Care Hospitals Group Measure Data Graphs o NSC-4 Falls with Injury <br>. Rehabilitation Hospitals Group Measure Data Graphs . Long-term Acute Care Hospitals Group Measure Data Graphs </p><p>April 2016 </p><ul style="display: flex;"><li style="flex:1">MHA </li><li style="flex:1">OCT 2007 </li></ul><p></p><p><strong>Analysis of the Statistical Significance of Hospital Measure Rates </strong></p><p>Because the measure rates for the hospitals are for a specific period of time, and because there is variability in performance over time because of chance and other factors, there is a degree of </p><p>uncertainty about the extent to which a hospital’s measure rate may reflect its true underlying </p><p>performance. Without taking this uncertainty into account, we cannot conclude that a hospital with a measure rate that is higher or lower than the group rate is truly performing at a worse or better rate than the group. </p><p>Statisticians use confidence intervals to account for this uncertainty. A confidence interval is a </p><p>numeric range around the estimate represented by the hospital’s measure rate, calculated to provide a </p><p>specified level of confidence that the interval includes the true underlying performance of the hospital. The&nbsp;confidence level chosen for this analysis, 95% confidence, means that, in repeated collection and analysis of similar data, 95% of the resulting confidence intervals will include the true rate. The&nbsp;use and interpretation of confidence intervals in the nursing-sensitive measures is illustrated below. For any hospital (A, B, C, or D), the measure rate represented by the square is </p><p>accompanied by a confidence interval (horizontal line). When a hospital’s confidence interval does </p><p>not intersect the group interval, represented by the vertical lines (hospitals A and D in the illustration), we can say that the difference between the hospital rate and the group rate is statistically </p><p>significant and likely represents a true difference in performance. When the hospital’s interval </p><p>completely crosses the group interval (hospitals B and C in the illustration), the difference is not </p><p>statistically significant.&nbsp;(When a hospital’s interval extends only a small distance into the group </p><p>interval, the difference may be statistically significant.&nbsp;Additional calculation is required.) The confidence level of 95% applies to the confidence interval for each individual hospital.&nbsp;In a group of 20 hospitals, one would expect, on average, that one confidence interval does not actually </p><p>include the hospital’s true rate. Hospitals’ confidence intervals will vary in width because, among </p><p>other factors, the measure rate is based on more or fewer observations (i.e., patient days). Abt Associates Inc. advised MHA on the analytic approach and performed the statistical analysis. </p><p>April 2016 </p><p>Hospitals will be found within the section for their bed-size group. Hospitals are listed alphabetically within bed-size groups below. Not all hospitals will have data for each unit-type. The data graphs are presented in order of hospital-bed size group, low to high. </p><p><strong>Acute Care Hospitals </strong></p><p></p><ul style="display: flex;"><li style="flex:1"><strong>Less than 100 Beds </strong></li><li style="flex:1"><strong>200 - 299 Beds </strong></li></ul><p></p><p></p><ul style="display: flex;"><li style="flex:1">Athol Hospital </li><li style="flex:1">Berkshire Medical Center </li></ul><p>Baystate Franklin Medical Center Baystate Mary Lane Hospital Baystate Noble Hospital <br>Cape Cod Hospital Good Samaritan Medical Center Holy Family Hospital and Medical Center </p><ul style="display: flex;"><li style="flex:1">Mount Auburn Hospital </li><li style="flex:1">Baystate Wing Hospital </li></ul><p>Beth Israel Deaconess Hospital - Milton Beth Israel Deaconess Hospital - Needham Clinton Hospital <br>Newton-Wellesley Hospital North Shore Medical Center - Salem Hospital Northeast Health System - Beverly Hospital </p><ul style="display: flex;"><li style="flex:1">Norwood Hospital </li><li style="flex:1">Fairview Hospital </li></ul><p></p><ul style="display: flex;"><li style="flex:1">Falmouth Hospital </li><li style="flex:1">Saint Vincent Hospital </li></ul><p>Marlborough Hospital Massachusetts Eye &amp; Ear Nashoba Valley Medical Center <br>Signature Healthcare Brockton Hospital Winchester Hospital </p><p>Northeast Health System - Addison Gilbert Hospital Southcoast Hospitals Group - Tobey Hospital </p><p><strong>300 - 399 Beds </strong></p><p>Lahey Hospital &amp; Medical Center Lowell General Hospital </p><p><strong>100 - 199 Beds </strong></p><p>Anna Jaques Hospital <br>Sisters of Providence Health System - Mercy Medical Center South Shore Hospital <br>Beth Israel Deaconess Hospital-Plymouth Brigham and Women's&nbsp;- Faulkner Hospital Cambridge Health Alliance - The Cambridge Hospital Cambridge Health Alliance - Whidden Hospital Carney Hospital <br>Southcoast Hospitals Group - Charlton Memorial Southcoast Hospitals Group - St. Luke's&nbsp;Hospital St. Elizabeth's Medical Center Tufts Medical Center </p><p>Cooley Dickinson Hospital </p><p><strong>500 or More Beds </strong></p><p></p><ul style="display: flex;"><li style="flex:1">Baystate Medical Center </li><li style="flex:1">Emerson Hospital </li></ul><p>Hallmark Health System - Lawrence Memorial Hospital Hallmark Health System - Melrose Wakefield Hospital Harrington Memorial Hospital HealthAlliance (UMASS Memorial&nbsp;HealthAlliance) - Leominster Heywood Hospital <br>Beth Israel Deaconess Medical Center Boston Medical Center Brigham and Women's Hospital Massachusetts General Hospital UMass Memorial Medical Center <br>Holy Family Hospital at Merrimack Valley Holyoke Medical Center Lawrence General Hospital MetroWest Medical Center - Framingham Campus MetroWest Medical Center - Leonard Morse Campus Milford Regional Medical Center Morton Hospital New England Baptist Hospital North Shore Medical Center - Union Hospital Saint Anne's Hospital Sturdy Memorial Hospital </p><p>April 2016 </p><p>Hospitals will be found within the section for their hospital type. Hospitals are listed alphabetically within hospital type below. Not all hospitals will have data for each unit-type. Specialty hospital data graphs follow the acute care hospital data graphs in this document. </p><p><strong>Specialty Hospitals </strong></p><p><strong>Rehabilitation Hospitals </strong></p><p>The Center for Rehabilitation at Berkshire Medical Center Braintree Rehabilitation Center Fairlawn Rehabilitation Hospital HealthAlliance (UMASS Memorial HealthAlliance) - Burbank HEALTHSOUTH Rehabilitation Hospital of Western MA Weldon Rehabilitation Hospital at Mercy Medical Center New England Rehabilitation Hospital Bronson Rehabilitation Center at Baystate Noble Hospital Southeast Rehabilitation Hospital at Southcoast Hospitals Group - Charlton Hospital Spaulding Rehabilitation Hospital Boston Spaulding Rehabilitation Hospital Cape Cod </p><p><strong>Long-Term Acute Care Hospitals </strong></p><p>Hebrew Rehabilitation Center Kindred Hospital Northeast - Stoughton New England Sinai Hospital Spaulding Hospital for Continuing Medical Care Cambridge Tewksbury Hospital </p><p>April 2016 </p><p>Acute Care Hospitals </p><p>April 2016 </p><p>NSC-2 Pressure Ulcer Prevalence <br>,<br>March 2015, June 2015*, September 2015 and <br>December 2015* </p><p>* Optional studies </p><p>April 2016 </p><p>Adult Critical Care Units, Less than 100 beds </p><p>Beth Israel Deaconess Hospital - Milton Baystate Noble Hospital Falmouth Hospital Nashoba Valley Medical Center Beth Israel Deaconess Hospital - Needham </p><p>Baystate Wing Hospital Hallmark Health System - Lawrence Memorial Hospital Fairview Hospital Baystate Franklin Medical Center Northeast Health System - Addison Gilbert Hospital Massachusetts Eye and Ear Southcoast Health - Tobey Hospital Marlborough Hospital </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">20.00% </li><li style="flex:1">40.00% </li><li style="flex:1">60.00% </li><li style="flex:1">80.00% </li><li style="flex:1">100.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Critical Care Units, 100-199 beds </p><p>Sturdy Memorial Hospital HealthAlliance (UMASS Memorial HealthAlliance) - Leominster MetroWest Medical Center - Framingham Campus North Shore Medical Center (NSMC) - Union Hospital MetroWest Medical Center - Leonard Morse Campus New England Baptist Hospital Cambridge Health Alliance - Whidden Hospital Anna Jaques Hospital Milford Regional Medical Center Holyoke Medical Center Cooley Dickinson Hospital Hallmark Health System - Melrose Wakefield Hospital Heywood Hospital Holy Family Hospital at Merrimack Valley </p><p>Cambridge Health Alliance - The Cambridge Hospital Morton Hospital and Medical Center Beth Israel Deaconess Hospital-Plymouth Carney Hospital Emerson Hospital Lawrence General Hospital Saint Anne's Hospital Brigham &amp; Women&nbsp;s Faulkner Hospital Harrington Memorial Hospital </p><p>00.00% 5.00%&nbsp;10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% </p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Critical Care Units, 200-299 beds </p><p>Saint Vincent Hospital Signature Healthcare Brockton Hospital Berkshire Medical Center Mount Auburn Hospital Holy Family Hospital Norwood Hospital Northeast Health System - Beverly Hospital North Shore Medical Center (NSMC) - Salem Hospital Newton-Wellesley Hospital Good Samaritan Medical Center Winchester Hospital Cape Cod Hospital </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">5.00% </li><li style="flex:1">10.00% </li><li style="flex:1">15.00% </li><li style="flex:1">20.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Critical Care Units, 300-399 beds </p><p>Sisters of Providence Health System - Mercy Medical Center St. Elizabeth's Medical Center South Shore Hospital Lowell General Hospital Tufts Medical Center Southcoast Health - St. Luke's Hospital </p><p>Lahey Hospital &amp; Medical Center Southcoast Health - Charlton Memorial Hospital </p><p>00.00% 2.00% 4.00% 6.00% 8.00%&nbsp;10.00% 12.00% 14.00% 16.00% 18.00% 20.00% </p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Critical Care Units, More than 500 beds </p><p>Baystate Medical Center UMass Memorial Medical Center Boston Medical Center Massachusetts General Hospital Brigham and Women's Hospital Beth Israel Deaconess Medical Center </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">2.00% </li><li style="flex:1">4.00% </li><li style="flex:1">6.00% </li><li style="flex:1">8.00% </li><li style="flex:1">10.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Step-Down Units, Less than 100 beds </p><p>Baystate Noble Hospital </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">1.00% </li><li style="flex:1">2.00% </li><li style="flex:1">3.00% </li><li style="flex:1">4.00% </li><li style="flex:1">5.00% </li><li style="flex:1">6.00% </li><li style="flex:1">7.00% </li><li style="flex:1">8.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Step-Down Units, 100-199 beds </p><p>Saint Anne's Hospital Holyoke Medical Center Cooley Dickinson Hospital Milford Regional Medical Center MetroWest Medical Center - Framingham Campus </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">2.00% </li><li style="flex:1">4.00% </li><li style="flex:1">6.00% </li><li style="flex:1">8.00% </li><li style="flex:1">10.00% </li><li style="flex:1">12.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Step-Down Units, 200-299 beds </p><p>Signature Healthcare Brockton Hospital Northeast Health System - Beverly Hospital </p><p>Berkshire Medical Center Cape Cod Hospital Mount Auburn Hospital Saint Vincent Hospital </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">2.00% </li><li style="flex:1">4.00% </li><li style="flex:1">6.00% </li><li style="flex:1">8.00% </li><li style="flex:1">10.00% 12.00% 14.00% 16.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Step-Down Units, 300-399 beds </p><p>Sisters of Providence Health System - Mercy Medical Center Lowell General Hospital Southcoast Health - St. Luke's Hospital </p><p>Southcoast Health - Charlton Memorial Hospital </p><p>Tufts Medical Center </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">2.00% </li><li style="flex:1">4.00% </li><li style="flex:1">6.00% </li><li style="flex:1">8.00% </li><li style="flex:1">10.00% </li><li style="flex:1">12.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Step-Down Units, More than 500 beds </p><p>UMass Memorial Medical Center Baystate Medical Center Beth Israel Deaconess Medical Center </p><p>Boston Medical Center </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">2.00% </li><li style="flex:1">4.00% </li><li style="flex:1">6.00% </li><li style="flex:1">8.00% </li><li style="flex:1">10.00% </li><li style="flex:1">12.00% </li><li style="flex:1">14.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Medical Units, Less than 100 beds </p><p>Northeast Health System - Addison Gilbert Hospital Clinton Hospital </p><p>00.00% 5.00%&nbsp;10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00% </p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Medical Units, 100-199 beds </p><p>Lawrence General Hospital MetroWest Medical Center - Framingham Campus Saint Anne's Hospital Milford Regional Medical Center Brigham &amp; Women&nbsp;s Faulkner Hospital Hallmark Health System - Melrose Wakefield Hospital North Shore Medical Center (NSMC) - Union Hospital </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">2.00% </li><li style="flex:1">4.00% </li><li style="flex:1">6.00% </li><li style="flex:1">8.00% 10.00%&nbsp;12.00% 14.00% 16.00% 18.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Medical Units, 200-299 beds </p><p>Northeast Health System - Beverly Hospital Good Samaritan Medical Center Norwood Hospital Winchester Hospital Saint Vincent Hospital North Shore Medical Center (NSMC) - Salem Hospital Newton-Wellesley Hospital Holy Family Hospital </p><p>00.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00%&nbsp;10.00% </p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Medical Units, 300-399 beds </p><p>St. Elizabeth's Medical Center South Shore Hospital Southcoast Health - St. Luke's Hospital </p><p>Tufts Medical Center </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">1.00% </li><li style="flex:1">2.00% </li><li style="flex:1">3.00% </li><li style="flex:1">4.00% </li><li style="flex:1">5.00% </li><li style="flex:1">6.00% </li><li style="flex:1">7.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Medical Units, More than 500 beds </p><p>Boston Medical Center Baystate Medical Center UMass Memorial Medical Center Brigham and Women's Hospital Beth Israel Deaconess Medical Center </p><p>Massachusetts General Hospital </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">0.50% </li><li style="flex:1">1.00% </li><li style="flex:1">1.50% </li><li style="flex:1">2.00% </li><li style="flex:1">2.50% </li><li style="flex:1">3.00% </li><li style="flex:1">3.50% </li><li style="flex:1">4.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Surgical Units, Less than 100 beds </p><p>Falmouth Hospital </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">1.00% </li><li style="flex:1">2.00% </li><li style="flex:1">3.00% </li><li style="flex:1">4.00% </li><li style="flex:1">5.00% </li><li style="flex:1">6.00% </li><li style="flex:1">7.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Surgical Units, 100-199 beds </p><p>North Shore Medical Center (NSMC) - Union Hospital Cooley Dickinson Hospital New England Baptist Hospital Brigham &amp; Women&nbsp;s Faulkner Hospital </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">2.00% </li><li style="flex:1">4.00% </li><li style="flex:1">6.00% </li><li style="flex:1">8.00% </li><li style="flex:1">10.00% </li><li style="flex:1">12.00% </li><li style="flex:1">14.00% </li><li style="flex:1">16.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Surgical Units, 200-299 beds </p><p>Newton-Wellesley Hospital Saint Vincent Hospital North Shore Medical Center (NSMC) - Salem Hospital </p><p>Mount Auburn Hospital Northeast Health System - Beverly Hospital </p><p>Winchester Hospital Holy Family Hospital </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">2.00% </li><li style="flex:1">4.00% </li><li style="flex:1">6.00% </li><li style="flex:1">8.00% </li><li style="flex:1">10.00% 12.00% 14.00% 16.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Surgical Units, 300-399 beds </p><p>Southcoast Health - St. Luke's Hospital Southcoast Health - Charlton Memorial Hospital </p><p>St. Elizabeth's Medical Center South Shore Hospital Tufts Medical Center </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">1.00% </li><li style="flex:1">2.00% </li><li style="flex:1">3.00% </li><li style="flex:1">4.00% </li><li style="flex:1">5.00% </li><li style="flex:1">6.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Surgical Units, More than 500 beds </p><p>Boston Medical Center Baystate Medical Center Brigham and Women's Hospital Massachusetts General Hospital UMass Memorial Medical Center </p><p>0</p><ul style="display: flex;"><li style="flex:1">0.00% </li><li style="flex:1">0.50% </li><li style="flex:1">1.00% </li><li style="flex:1">1.50% </li><li style="flex:1">2.00% </li><li style="flex:1">2.50% </li><li style="flex:1">3.00% </li><li style="flex:1">3.50% </li><li style="flex:1">4.00% </li></ul><p></p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Medical-Surgical Units, Less than 100 beds </p><p>Beth Israel Deaconess Hospital - Milton Baystate Franklin Medical Center Baystate Wing Hospital Beth Israel Deaconess Hospital - Needham Hallmark Health System - Lawrence Memorial Hospital Baystate Noble Hospital Nashoba Valley Medical Center Massachusetts Eye and Ear Fairview Hospital Baystate Mary Lane Hospital Clinton Hospital Athol Hospital Falmouth Hospital Southcoast Health - Tobey Hospital Marlborough Hospital </p><p>00.00% 2.00% 4.00% 6.00% 8.00%&nbsp;10.00% 12.00% 14.00% 16.00% 18.00% 20.00% </p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Medical-Surgical Units, 100-199 beds </p><p>Lawrence General Hospital Anna Jaques Hospital MetroWest Medical Center - Framingham Campus Cooley Dickinson Hospital Harrington Memorial Hospital Heywood Hospital Carney Hospital MetroWest Medical Center - Leonard Morse Campus Holyoke Medical Center New England Baptist Hospital Holy Family Hospital at Merrimack Valley Brigham &amp; Women&nbsp;s Faulkner Hospital Milford Regional Medical Center HealthAlliance (UMASS Memorial HealthAlliance) - Leominster Cambridge Health Alliance - The Cambridge Hospital Hallmark Health System - Melrose Wakefield Hospital Beth Israel Deaconess Hospital-Plymouth North Shore Medical Center (NSMC) - Union Hospital Sturdy Memorial Hospital Emerson Hospital Saint Anne's Hospital Cambridge Health Alliance - Whidden Hospital Morton Hospital and Medical Center </p><p>00.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00%&nbsp;10.00% </p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p><p>Adult Medical-Surgical Units, 200-299 beds </p><p>Berkshire Medical Center Signature Healthcare Brockton Hospital </p><p>Northeast Health System - Beverly Hospital North Shore Medical Center (NSMC) - Salem Hospital </p><p>Winchester Hospital Mount Auburn Hospital Norwood Hospital Cape Cod Hospital Good Samaritan Medical Center Saint Vincent Hospital </p><p>00.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00%&nbsp;10.00% </p><p><strong>Percent of Patients with Hospital Acquired Pressure Ulcers </strong></p>