OTSEGO MEMORIAL HOSPITAL (GAYLORD, MI) Detailed Hospital Profile

Process of Care

Heart Attack

Average number of minutes before outpatients with chest pain or possible heart attack got an ECG

Here:	8
State:	9

Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival

Here:	97.0%
State:	95.4%

Heart Failure

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

Here:	100.0%
Michigan:	99.5%

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

Here:	94.0%
State:	95.9%

Percent of Patients Given Discharge Instructions

This Hospital:	95.0%
Michigan:	92.1%

Pneumonia

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

This Hospital:	100.0%
State:	96.5%

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

This Hospital:	97.0%
State:	97.1%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	96.0%
Michigan:	98.8%

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

Here:	97.0%
State:	95.7%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	97.0%
State:	92.3%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	99.0%
State:	95.8%

Surgery

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

Here:	97.0%
Michigan:	98.3%

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

Here:	97.0%
Michigan:	97.3%

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

Here:	99.0%
Michigan:	98.5%

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

Here:	98.0%
Michigan:	97.5%

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

Here:	99.0%
Michigan:	98.4%

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%
Michigan:	99.8%

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

This Hospital:	100.0%
State:	93.2%

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

This Hospital:	94.0%
Michigan:	96.1%

Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)

Here:	98.0%
State:	93.9%

Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)

Here:	97.0%
Michigan:	95.7%

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

This Hospital:	99.0%
State:	99.7%

Outcome of Care

30-Day Mortality Rates from Heart Failure

This Hospital:	12.9%
State:	10.8%

30-Day Mortality Rates from Pneumonia

Here:	13.3%
Michigan:	11.4%

30-Day Readmission Rates from Heart Failure

This Hospital:	23.5%
State:	25.2%

30-Day Readmission Rates from Pneumonia

Here:	17.4%
Michigan:	18.7%

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

Here:	$14,222
Michigan:	$20,754

Average Total Payments

This Hospital:	$8,124
State:	$8,256

Number of discharges: 28

This Hospital:	7.71%
Michigan:	2.41%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

This Hospital:	$10,771
State:	$12,026

Average Total Payments

This Hospital:	$4,895
State:	$5,048

Number of discharges: 23

Here:	6.34%
Michigan:	1.55%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

Here:	$12,751
Michigan:	$13,870

Average Total Payments

This Hospital:	$4,838
State:	$5,175

Number of discharges: 13

Here:	3.58%
Michigan:	3.40%

Heart Failure and Shock with Complications

Average Covered Charges

This Hospital:	$8,556
State:	$17,110

Average Total Payments

This Hospital:	$6,524
State:	$7,317

Number of discharges: 20

This Hospital:	5.51%
Michigan:	3.09%

Heart Failure and Shock without Complications

Average Covered Charges

Here:	$7,106
Michigan:	$11,986

Average Total Payments

Here:	$4,717
Michigan:	$4,982

Number of discharges: 20

Here:	5.51%
Michigan:	1.13%

Hip and Femur Procedures Except Major Joint with Complications

Average Covered Charges

This Hospital:	$25,353
Michigan:	$34,665

Average Total Payments

This Hospital:	$13,326
Michigan:	$12,956

Number of discharges: 11

Here:	3.03%
Michigan:	0.86%

Intracranial Hemorrhage or Cerebral Infarction with Complications

Average Covered Charges

This Hospital:	$8,670
Michigan:	$20,410

Average Total Payments

Here:	$7,171
State:	$8,126

Number of discharges: 15

Here:	4.13%
State:	1.41%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

Here:	$7,353
State:	$12,900

Average Total Payments

Here:	$5,098
State:	$5,490

Number of discharges: 13

This Hospital:	3.58%
State:	2.37%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

Here:	$28,316
Michigan:	$34,590

Average Total Payments

Here:	$14,530
State:	$14,454

Number of discharges: 100

Here:	27.55%
State:	5.70%

Misc Disorders of Nutrition, Metabolism, Fluids or Electrolytes without Major Complications

Average Covered Charges

This Hospital:	$9,467
Michigan:	$11,978

Average Total Payments

This Hospital:	$4,760
Michigan:	$4,928

Number of discharges: 18

This Hospital:	4.96%
Michigan:	1.81%

Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with Major Complications

Average Covered Charges

Here:	$16,003
State:	$31,268

Average Total Payments

This Hospital:	$12,274
Michigan:	$13,308

Number of discharges: 13

This Hospital:	3.58%
State:	5.26%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

Here:	$12,110
Michigan:	$16,425

Average Total Payments

This Hospital:	$6,756
State:	$7,142

Number of discharges: 53

This Hospital:	14.60%
State:	2.16%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

This Hospital:	$9,199
State:	$11,947

Average Total Payments

This Hospital:	$4,942
Michigan:	$4,951

Number of discharges: 25

This Hospital:	6.89%
Michigan:	0.82%

Spinal Fusion Except Cervical without Major Complications

Average Covered Charges

This Hospital:	$56,440
State:	$59,725

Average Total Payments

Here:	$30,459
Michigan:	$26,977

Number of discharges: 11

Here:	3.03%
State:	1.02%

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: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide a safe, clean, comfortable and homelike environment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- 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: Some
Have enough backup water supply for essential areas of the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
- Harm: Potential for minimal harm
- Scope: Many
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Many
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
- 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
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Few

Use of Medical Imaging

Outpatients with low back pain who had an MRI without trying recommended treatments first, such as physical therapy.

Here:	48.700%
Michigan:	36.057%

Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram.

This Hospital:	11.600%
Michigan:	7.381%

Outpatient CT scans of the abdomen that were combination (double) scans.

Here:	0.044%
Michigan:	0.111%

Outpatient CT scans of the chest that were combination (double) scans.

This Hospital:	0.017%
Michigan:	0.051%

Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery

Here:	6.300%
State:	5.222%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 43%

How often did nurses communicate well with patients?

Sometimes or never

This Hospital:	4%
State:	4%

Usually

This Hospital:	18%
State:	18%

Always

Here:	78%
Michigan:	78%

How often did doctors communicate well with patients?

Sometimes or never

This Hospital:	4%
Michigan:	4%

Usually

Here:	16%
State:	17%

Always

This Hospital:	80%
Michigan:	79%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	6%
Michigan:	8%

Usually

Here:	25%
State:	24%

Always

Here:	69%
Michigan:	68%

How often was patients' pain well controlled?

Sometimes or never

Here:	9%
State:	6%

Usually

This Hospital:	24%
Michigan:	23%

Always

This Hospital:	67%
State:	71%

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

Sometimes or never

This Hospital:	18%
State:	20%

Usually

This Hospital:	15%
Michigan:	19%

Always

This Hospital:	67%
Michigan:	61%

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

Sometimes or never

This Hospital:	8%
Michigan:	9%

Usually

Here:	23%
Michigan:	20%

Always

Here:	69%
Michigan:	71%

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

Sometimes or never

This Hospital:	15%
Michigan:	12%

Usually

This Hospital:	34%
Michigan:	31%

Always

Here:	51%
Michigan:	57%

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

Yes

This Hospital:	85%
State:	86%

Here:	15%
Michigan:	14%

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

6 or lower

Here:	9%
Michigan:	8%

7 or 8

This Hospital:	28%
Michigan:	22%

9 or 10

This Hospital:	63%
State:	70%

Would patients recommend the hospital to friends and family?

This Hospital:	7%
Michigan:	5%

Yes, probably

This Hospital:	29%
State:	25%

Yes, definitely

Here:	64%
State:	70%

Quality Measures

Percent of short-stay residents who self-report moderate to severe pain

This Hospital:	55.1%
Michigan:	21.5%

Percent of short-stay residents with Pressure ulcers that are new or worsened

This Hospital:	1.8%
Michigan:	1.6%

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

This Hospital:	90.5%
State:	84.1%

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

Here:	84.2%
Michigan:	82.9%

OTSEGO MEMORIAL HOSPITAL - GAYLORD, MI

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Complaint Deficiency

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

Quality Measures

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