Pennsylvania Health Care Quality Alliance > Reports > Chan Soon-Shiong Medical Center at Windber

PHCQA Report of Hospital Quality

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Chan Soon-Shiong Medical Center at Windber

600 Somerset Avenue

Windber, PA 15963-1397

www.windbercare.com

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Green indicates that the hospital's result was better than or equal to the selected benchmark.

Black indicates that the hospital's result was below the selected benchmark.

Rollover the Questionmark for more information on the measure.

Rollover the Calendar to see the corresponding measurement period and number of patients included in the results.

Click the Compare Hospitals to compare other hospitals for this measure. Click the underlined measure name to view the hospital's historical data.

Appropriate Care

Appropriate Care Measures Indicates how often patients received all recommended treatments for their clinical condition.
The column highlighted in yellow is the benchmark to which the hospital is compared. Click other column headers to change the comparison.

  Chan Soon-Shiong Medical Center at Windber PA Rate PA Top 25% PA Top 10%
Overall Appropriate Care      66% 94% 98% 99%
   Heart Attack Care      N/A 96% 100% 100%
   Heart Failure Care      100% 100% 100% 100%
   Pneumonia Care      73% 97% 100% 100%
   Surgical Care      94% 97% 98% 100%
   Preventive Care      69% 93% 99% 100%
   Stroke Care      0% 95% 100% 100%
   Venous Thromboembolism Care      54% 95% 99% 100%

Healthcare-Associated Infections

Outcome Measures Measures hospital results in specific areas.

  Chan Soon-Shiong Medical Center at Windber    
Urinary Tract Infections (Catheter Associated)      N/A
Bloodstream Infections (Central Line Associated)      N/A
Colon Surgical Site Infections      Not significantly different than national infection rate
MRSA (Staph) Infections      N/A
C. Difficile Infections      Not significantly different than national infection rate

Heart Attack

Process Measures Measures how often hospitals are performing recommended tasks.
The column highlighted in yellow is the benchmark to which the Hospital is compared. Click other column headers to change the comparison.

  Chan Soon-Shiong Medical Center at Windber PA Rate US Rate Top 10% Nationally
Aspirin on Arrival      87% 99% 99% 100%
Aspirin Prescribed at Discharge      N/A 100% 99% 100%
ACEI or ARB for LVSD      100% 97% 97% 100%
Beta Blocker Prescribed at Discharge      88% 99% 99% 100%
PCI within 90 Minutes      N/A 96% 96% 100%
Statin Prescribed at Discharge      N/A 99% 99% 100%

Outcome Measures Measures hospital results in specific areas.

  Chan Soon-Shiong Medical Center at Windber PA Average    
30-Day Death Rate for Heart Attack Patients      N/A 13.1 %    
30-Day All-Cause Readmission Rate for Heart Attack Patients      N/A 16.3 %    
CABG Death Rate      N/A 1.5 %    

Heart Failure

Process Measures Measures how often hospitals are performing recommended tasks.
The column highlighted in yellow is the benchmark to which the Hospital is compared. Click other column headers to change the comparison.

  Chan Soon-Shiong Medical Center at Windber PA Rate US Rate Top 10% Nationally
Discharge Instructions      N/A 83% 92% 100%
ACEI or ARB for LVSD      N/A 98% 97% 100%

Outcome Measures Measures hospital results in specific areas.

  Chan Soon-Shiong Medical Center at Windber PA Average    
30-Day Death Rate for Heart Failure Patients      11.1 % 11.5 % No different than U.S. National Rate
30-Day All-Cause Readmission Rate for Heart Failure Patients      21.5 % 21.3 % No different than U.S. National Rate

Pneumonia

Process Measures Measures how often hospitals are performing recommended tasks.
The column highlighted in yellow is the benchmark to which the Hospital is compared. Click other column headers to change the comparison.

  Chan Soon-Shiong Medical Center at Windber PA Rate US Rate Top 10% Nationally
Pneumococcal Vaccination      92% 97% 96% 100%
Blood Culture within First 24 hours (ICU)      N/A 98% 98% 100%
Blood Culture prior to First Antibiotic      100% 98% 98% 100%
Initial Antibiotic within 6 Hours      95% 97% 96% 100%
Initial Antibiotic Selection      91% 97% 96% 100%
Initial Antibiotic Selection for ICU Patients      N/A 92% 89% 100%
Initial Antibiotic Selection for Non-ICU Patients      N/A 97% 97% 100%
Influenza Vaccination      97% 95% 94% 100%

Outcome Measures Measures hospital results in specific areas.

  Chan Soon-Shiong Medical Center at Windber PA Average    
30-Day Death Rate for Pneumonia Patients      15.5 % 15.7 % No different than U.S. National Rate
30-Day All-Cause Readmission Rate for Pneumonia Patients      16.4 % 16.8 % No different than U.S. National Rate

Surgical Care and Infection Prevention

Process Measures Measures how often hospitals are performing recommended tasks.
The column highlighted in yellow is the benchmark to which the Hospital is compared. Click other column headers to change the comparison.

  Chan Soon-Shiong Medical Center at Windber PA Rate US Rate Top 10% Nationally
Beta Blocker during the Perioperative Period      100% 99% 98% 100%
Prophylactic Antibiotic within 1 hour of incision      [ + ] 98% 99% 99% 100%
Appropriate Antibiotic      [ + ] 99% 99% 99% 100%
Prophylactic Antibiotic Discontinued within 24 hours      [ + ] 97% 99% 98% 100%
Cardiac Surgery Patients with Controlled 6 A.M. Postoperative Blood Glucose      N/A 94% 94% 100%
Urinary Catheter Removal within Two Days of Surgery      96% 99% 98% 100%
Surgery Patients with Perioperative Temperature Management      N/A 100% 100% 100%
VTE Ordered prior to Surgery      99% 99% 98% 100%
VTE Received within 24 Hours of Surgery      99% 100% 100% 100%

Blood Clots (VTE)

Process Measures Measures how often hospitals are performing recommended tasks.
The column highlighted in yellow is the benchmark to which the Hospital is compared. Click other column headers to change the comparison.

  Chan Soon-Shiong Medical Center at Windber PA Rate US Rate Top 10% Nationally
Blood Clot Prevention      68% 96% 94% 100%
ICU Blood Clot Prevention      57% 98% 97% 100%
Appropriate Blood Clot Treatment Using Two Blood Thinners      82% 94% 94% 100%
Heparin with Platelet Count Monitoring      N/A 100% 99% 100%
Warfarin Discharge Instructions      N/A 92% 93% 100%
Potentially Preventable VTE      N/A 1% 2% 0%

Consumer Assessment

Patient Experience Measures Measures various aspects of patients’ experiences during their hospital stay.
The column highlighted in yellow is the benchmark to which the hospital is compared. Click other column headers to change the comparison.

  Chan Soon-Shiong Medical Center at Windber PA Avg US Avg Top 10% Nationally
Doctor Communication      89% 81% 82% 89%
Nurse Communication      82% 81% 80% 87%
Responsiveness of Hospital Staff      73% 68% 69% 81%
Pain Well Controlled      73% 71% 71% 78%
Medicine Explained by Staff      62% 64% 65% 74%
Room and Bathroom Kept Clean      76% 74% 75% 85%
Room Quiet at Night      58% 56% 63% 76%
Provided Discharge Information      88% 88% 87% 92%
Care Transition      56% 52% 52% 61%
Hospital Rating      75% 71% 73% 83%
Hospital Recommendation      77% 70% 72% 84%

Prevention

Process Measures Measures how often hospitals are performing recommended tasks.
The column highlighted in yellow is the benchmark to which the Hospital is compared. Click other column headers to change the comparison.

  Chan Soon-Shiong Medical Center at Windber PA Rate US Rate Top 10% Nationally
Pnuemococcal Immunization      82% 92% 92% 99%
Influenza Immunization      67% 94% 93% 100%
Flu Vaccine for Health Care Workers      87% 91% 88% 99%

Emergency Department

System Measures Measures reflect the way in which whole "systems" of care (hospitals, doctor offices, nursing homes, etc.) work. As a result, these measures may or may not be specifically indicative of Hospital quality.

Emergency Department (ED) Measures Display how timely and effective the care in a hospital's emergency department is delivered. Measures which show ED timeliness of care are displayed as an average in minutes, and thus may not reflect daily fluctuations of ED care. For these measures, a lower score in better. Please note that all ED measures are based on a limited sample each quarter and do not reflect the median score of all ED patients.

  Chan Soon-Shiong Medical Center at Windber PA Average US Average  
Time from Emergency Department (ED) Arrival to ED Departure for Admitted Patients      216 Minutes 280 Minutes 282 Minutes  
Time from Admit Decision to Departure Time from the Emergency Department (ED) for Admitted Patients      66 Minutes 106 Minutes 102 Minutes  
Median Time From ED Arrival to ED Departure for Discharged ED Patients      132 Minutes 142 Minutes 138 Minutes  
Door to Diagnostic Evaluation by a Qualified Medical Professional      22 Minutes 22 Minutes 20 Minutes  
ED-Median Time to Pain Management for Long Bone Fracture      71 Minutes 56 Minutes 49 Minutes  
ED-Patient Left Without Being Seen      1% 2% 2%  

*These PA and US rates are case-weighted averages, which are calculated by dividing the total number of patients/cases that meet the received the recommended care according to the measure’s criteria by the total number of patients/cases that are eligible to be counted based on the measure’s inclusion criteria for all facilities included in the specified Hospital population.

**The Hospital quality measures reported on this website come from a variety of sources using several data collection processes and update schedules. While the PHCQA website contains the most recent publicly available information, the time periods represented by these data range from 6 to 24 months old. Caution should be used when drawing conclusions from these data as a Hospital’s performance may have changed significantly since the data was collected and reported. The PHCQA recommends you contact the Hospital directly to obtain the most recent performance data.