To find a doctor, call 800-667-5356 or click below:

Find a Doctor

Request an Appointment

left banner
right banner
Smaller Larger

Publicly Reported Quality Measures

Some measures are service specific. They tell us about the quality and safety provided in a specific clinical area, such as heart care or orthopaedics. Other measures are hospital-wide and are not dependent upon whether the patient is receiving heart care or orthopaedic care. On this page, you will find hospital-wide quality performance measures for Infection Prevention and Nursing Care, as well as quality performance measures for Common Conditions such as Heart Care, Pneumonia Care, and Surgical Care.

Infection Prevention

Infections are a serious concern in hospitals. Nationwide, 2.5 million patients develop healthcare-associated infections annually. Not only do infections cause additional medical problems for patients, but they can increase the time a patient spends in the hospital, and sometime, can result in serious illness. The risk of healthcare-associated infections can be reduced by following best practices for infection control. Learn more about what BIDMC is doing to address this problem in several important areas.

Infections BIDMC Performance1
Q4 FY 12
BIDMC Goal3
Preventing Ventilator Associated Pneumonia
A higher score is better.
98% 90%
Infections BIDMC Performance1
Q4 FY 12
BIDMC Goal3
Central Line Associated Blood Stream Infections in ICUs
A lower score is better.
2.78 1.71

Hand Hygiene BIDMC Performance1
Q4 FY 12
BIDMC Goal3
Hand Hygiene: Intensive Care Unit
A higher score is better
92% 90%
Hand Hygiene: Medical-Surgical
A higher score is better
68% 90%

Nursing Care

Nursing care at BIDMC is dedicated to providing the highest quality of care and safety to our patients. As part of this commitment, BIDMC nursing puts itself “under the microscope” and monitors several nursing core areas for quality and safety. Below you can see how we are doing in several key aspects of nursing care, including pressure ulcers and patient falls. For more information about each measure and its benchmark, click on the name of the measure.

Nursing Care
BIDMC Performance1
Q4 FY 12
Benchmark Comparison2 BIDMC Goal3
Pressure Ulcers - Stage II &
Above: Medical Units

A lower score is better
0.00% 1.32% 0%
Pressure Ulcers - Stage II & Above: Medical-Surgical Units
A lower score is better
0.00% 1.13% 0%

Nursing Care
BIDMC Performance1
Q4 FY 12
Benchmark Comparison2 BIDMC Goal3
Patient Falls - Medical Units
A lower score is better
2.60 3.54 2.49
Patient Falls -Medical-Surgical Units
A lower score is better
2.05 3.90 2.05

Heart Care: Performance Summary

In 2010, over 1,300 patients were admitted to BIDMC with heart failure or acute myocardial infarction (AMI - more commonly referred to as a heart attack). Learn more about heart care at BIDMC >>

All of our patients should receive care that is likely to achieve the best possible results. The information below tells you how closely BIDMC has been following recommended guidelines for some measures of general heart care: treatment of heart attack and heart failure.

For more information about each measure and its benchmark, click on the name of the measure.

Appropriate and Timely Treatment
for Heart Attack
BIDMC Performance1
4th Qtr FY 2012
Top 10%(4)
10/10-09/11
ACE Inhibitors and ARB's
A higher score is better
100% 100%
Administering aspirin on arrival
A higher score is better
100% 100%

Prevention of Future
Heart Attacks
BIDMC Performance1
4th Qtr FY 2012
Top 10%(4)
10/10-09/11
Administering aspirin at discharge
A higher score is better
100% 100%
Administering beta blockers at discharge
A higher score is better
100% 100%
Advice to stop smoking
A higher score is better
100% 100%

Post Discharge Outcomes BIDMC Performance1
07/08-06/11
US National Performance4
07/08-06/11
Heart Attack 30-day Mortality
A lower score is better
12.1% 15.5%
Heart Attack 30-day Readmission
A lower score is better
22.9% 19.7%

Appropriate and Timely Treatment
for Heart Failure
BIDMC Performance1
4th Qtr FY 2012
Top 10%(4)
10/10-09/11
Assessment of left ventricular function
A higher score is better
99% 100%

Prevention of Future
Heart Failure
BIDMC Performance1
4th Qtr FY 2012
Top 10%(4)
10/10-09/11
Prescribing ACE Inhibitors and ARBs on discharge
A higher score is better
100% 100%
Providing discharge instructions for self- management
A higher score is better
100% 100%
Advice to stop smoking
A higher score is better
100% 100%

Post Discharge Outcomes BIDMC Performance1
07/08-06/11
US National Performance4
07/08-06/11
Heart Failure 30-day Mortality
A lower score is better
9.0% 11.6%
Heart Failure
30-day Readmission

A lower score is better
27.6% 24.7%

Pneumonia: Performance Summary

Patients who are admitted to BIDMC with pneumonia should receive those elements of care that are demonstrated to lead to the best results. The information below tells you how closely BIDMC has been following recommended guidelines for pneumonia care.

For more information about each measure and its benchmark, click on the name of the measure.

Pneumonia:
Appropriate Treatment
BIDMC Performance1
4th Qtr FY 2012
Top 10%(4)
10/10-09/11
Performing blood cultures
A higher score is better
100% 100%
Choosing appropriate antibiotics
A higher score is better
95% 100%
Pneumonia Care: Outcomes BIDMC Performance1
07/08-06/11
US National Performance4
07/08-06/11
Pneumonia 30-day Mortality
A lower score is better
8.4% 12.0%
Pneumonia 30-day Readmission
A lower score is better
21.6% 18.5%

Surgical Care: Infection Prevention Performance Summary

Prevention of
Post-Surgical Infections
BIDMC Performance1
4th Qtr FY 2012
Top 10%(4)
10/10-09/11
Administering timely medication
A higher score is better.
100% 100%
Reducing risks associated with antibiotics
A higher score is better.
99% 100%
Selecting appropriate antibiotics
A higher score is better.
99% 100%

Surgical Care: Infection Prevention Outcomes Summary

Surgical Site Infections: Hip & Knee Replacement Surgery BIDMC Performance1
4th Qtr FY 12
Comparison3
Surgical Site Infection Rate for Elective Hip Replacement Surgery (per 100 surgeries)
A lower score is better.
3.6 0.9
Surgical Site Infection Rate for Trauma-Related Hip Replacement Surgery (per 100 surgeries)
A lower score is better.
0.0 1.1
Surgical Site Infection Rate for Knee Replacement Surgery (per 100 surgeries)
A lowerscore is better.
2.2 1.5

1Source of this data is from hospital administrative databases, and reflects data reported to regulatory agencies.
2Souce of comparison data for Pressure Ulcers and Patient Falls is Massachusetts PatientCareLink.
3The 2012 Goal for BIDMC is based on a review of a nationally recognized database of comparable institutions, or drawn from internal benchmarks that BIDMC has established, and is based upon hospital performance data reported regulatory agencies.
4The source of the comparison for these measures is Hospital Compare, Centers for Medicare & Medicaid Services, January, 2013. The data reported for this set of measures are drawn from a representative sample of patients rather than all surgical patients.


Last updated: January 25, 2013

Contact Information

Silverman Institute for Health Care Quality and Safety
Beth Israel Deaconess Medical Center
330 Brookline Ave
Boston, MA 02215
617-667-1325