MINISTRY DOOR COUNTY MEDICAL CENTER (STURGEON BAY, WI) Detailed Hospital Profile

Process of Care

Heart Failure

Percent of patients who were given an evaluation of Left Ventricular Systolic Dysfunction (LVSD)

This Hospital:	98.0%
Wisconsin:	98.3%

Percent of Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)

Here:	69.0%
State:	95.6%

Percent of Patients Given Discharge Instructions

Here:	91.0%
Wisconsin:	91.1%

Pneumonia

Percent of Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

Here:	96.0%
State:	97.9%

Percent of Patients Whose Initial ER Blood Culture Was Performed Prior To Administration Of First Dose Of Antibiotics

Here:	95.0%
State:	97.6%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	86.0%
Wisconsin:	97.1%

Percent of Patients Given the Most Appropriate Initial Antibiotic(s)

Here:	87.0%
Wisconsin:	95.6%

Percent of Patients Assessed and Given Influenza Vaccination

This Hospital:	87.0%
State:	93.4%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	88.0%
Wisconsin:	96.3%

Surgery

Percent of Surgery Patients given an antibiotic at the right time (within one hour before surgery) to help prevent infection

Here:	96.0%
State:	97.9%

Percent of Surgery Patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)

Here:	95.0%
Wisconsin:	97.5%

Percent of Surgery Patients who were given the right kind of antibiotic to help prevent infection

Here:	99.0%
State:	99.0%

Percent of Surgery Patients who got treatment at right time (within 24 hours before or after surgery) to help prevent blood clot

Here:	95.0%
State:	97.0%

Percent of Surgery Patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries

This Hospital:	97.0%
State:	97.7%

Percent of Surgery Patients needing hair removed from the surgical area before surgery who had hair removed using a safer method

This Hospital:	100.0%
State:	99.9%

Percent of Surgery Patients whose urinary catheters were removed on the first or second day after surgery

Here:	88.0%
State:	94.2%

Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on them

This Hospital:	94.0%
Wisconsin:	95.3%

Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal

This Hospital:	99.0%
State:	99.6%

Outcome of Care

30-Day Mortality Rates from Heart Failure

This Hospital:	11.9%
State:	11.7%

30-Day Mortality Rates from Pneumonia

This Hospital:	10.6%
Wisconsin:	11.9%

30-Day Readmission Rates from Heart Failure

Here:	20.6%
Wisconsin:	23.7%

30-Day Readmission Rates from Pneumonia

This Hospital:	17.8%
Wisconsin:	18.1%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 39%

How often did nurses communicate well with patients?

Sometimes or never

Here:	1%
Wisconsin:	3%

Usually

This Hospital:	13%
State:	17%

Always

Here:	86%
Wisconsin:	80%

How often did doctors communicate well with patients?

Sometimes or never

Here:	3%
Wisconsin:	3%

Usually

This Hospital:	13%
State:	15%

Always

This Hospital:	84%
Wisconsin:	82%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	4%
State:	6%

Usually

This Hospital:	17%
State:	24%

Always

Here:	79%
Wisconsin:	70%

How often was patients' pain well controlled?

Sometimes or never

This Hospital:	4%
State:	5%

Usually

This Hospital:	17%
Wisconsin:	24%

Always

This Hospital:	79%
State:	71%

How often did staff explain about medicines before giving them to patients?

Sometimes or never

This Hospital:	14%
Wisconsin:	15%

Usually

This Hospital:	19%
Wisconsin:	18%

Always

Here:	67%
State:	67%

How often were the patients' rooms and bathrooms kept clean?

Sometimes or never

Here:	3%
Wisconsin:	5%

Usually

This Hospital:	11%
State:	17%

Always

This Hospital:	86%
State:	78%

How often was the area around patients' rooms kept quiet at night?

Sometimes or never

Here:	4%
State:	8%

Usually

This Hospital:	22%
State:	30%

Always

Here:	74%
Wisconsin:	62%

Were patients given information about what to do during their recovery at home?

Yes

This Hospital:	87%
State:	87%

Here:	13%
State:	13%

How do patients rate the hospital overall on a scale from 0 (lowest) to 10 (highest)?

6 or lower

Here:	4%
Wisconsin:	6%

7 or 8

This Hospital:	18%
Wisconsin:	21%

9 or 10

Here:	78%
Wisconsin:	73%

Would patients recommend the hospital to friends and family?

This Hospital:	3%
Wisconsin:	3%

Yes, probably

This Hospital:	19%
State:	24%

Yes, definitely

This Hospital:	78%
State:	73%

Quality Measures

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Hospital:	100.0%
State:	92.1%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	95.2%
Wisconsin:	92.0%

Complaint Deficiency

Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Weekly inspections and monthly testing of generators
- Harm: Potential for minimal harm
- Scope: Many
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridors that are separated from common areas by walls constructed to limit the passage of smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An automatic smoke detection system in all hallways
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly sized and located linen or trash receptacles
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many

MINISTRY DOOR COUNTY MEDICAL CENTER - STURGEON BAY, WI

Process of Care

Heart Failure

Pneumonia

Surgery

Outcome of Care

Hospital Consumer Assessment of Healthcare Providers

Quality Measures

Complaint Deficiency

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