Pennsylvania Health Care Quality Alliance > Reports > WellSpan Ephrata Community Hospital

PHCQA Report of Hospital Quality

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WellSpan Ephrata Community Hospital

169 Martin Avenue

Ephrata, PA 17522-1755

www.wellspan.org

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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.

  WellSpan Ephrata Community Hospital PA Rate PA Top 25% PA Top 10%
Overall Appropriate Care      98% 94% 98% 99%
   Heart Attack Care      N/A 96% 100% 100%
   Heart Failure Care      100% 100% 100% 100%
   Pneumonia Care      95% 97% 100% 100%
   Surgical Care      94% 97% 98% 100%
   Preventive Care      99% 93% 99% 100%
   Stroke Care      89% 95% 100% 100%
   Venous Thromboembolism Care      99% 95% 99% 100%

Healthcare-Associated Infections

Outcome Measures Measures hospital results in specific areas.

  WellSpan Ephrata Community Hospital    
Urinary Tract Infections (Catheter Associated)      Not significantly different than national infection rate
Bloodstream Infections (Central Line Associated)      Not significantly different than national infection rate
Colon Surgical Site Infections      Not significantly different than national infection rate
MRSA (Staph) Infections      N/A
C. Difficile Infections      Significantly lower 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.

  WellSpan Ephrata Community Hospital PA Rate US Rate Top 10% Nationally
Aspirin on Arrival      100% 99% 99% 100%
Aspirin Prescribed at Discharge      N/A 100% 99% 100%
ACEI or ARB for LVSD      0% 97% 97% 100%
Beta Blocker Prescribed at Discharge      93% 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.

  WellSpan Ephrata Community Hospital PA Average    
30-Day Death Rate for Heart Attack Patients      13.0 % 12.7 % No different than U.S. National Rate
30-Day All-Cause Readmission Rate for Heart Attack Patients      16.1 % 16.1 % No different than U.S. National Rate
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.

  WellSpan Ephrata Community Hospital PA Rate US Rate Top 10% Nationally
Discharge Instructions      N/A 83% 92% 100%
ACEI or ARB for LVSD      96% 98% 97% 100%

Outcome Measures Measures hospital results in specific areas.

  WellSpan Ephrata Community Hospital PA Average    
30-Day Death Rate for Heart Failure Patients      12.4 % 11.4 % No different than U.S. National Rate
30-Day All-Cause Readmission Rate for Heart Failure Patients      17.9 % 21.1 % Better 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.

  WellSpan Ephrata Community Hospital PA Rate US Rate Top 10% Nationally
Pneumococcal Vaccination      100% 97% 96% 100%
Blood Culture within First 24 hours (ICU)      97% 98% 98% 100%
Blood Culture prior to First Antibiotic      97% 98% 98% 100%
Initial Antibiotic within 6 Hours      93% 97% 96% 100%
Initial Antibiotic Selection      97% 97% 96% 100%
Initial Antibiotic Selection for ICU Patients      92% 92% 89% 100%
Initial Antibiotic Selection for Non-ICU Patients      96% 97% 97% 100%
Influenza Vaccination      98% 95% 94% 100%

Outcome Measures Measures hospital results in specific areas.

  WellSpan Ephrata Community Hospital PA Average    
30-Day Death Rate for Pneumonia Patients      15.9 % 15.6 % No different than U.S. National Rate
30-Day All-Cause Readmission Rate for Pneumonia Patients      14.9 % 16.5 % No different than U.S. National Rate

Cancer Care

Process Measures Measures how often hospitals are performing recommended tasks. While a higher rate is considered better, please note that hospitals are not necessarily expected to reach 100% compliance.
The column highlighted in yellow is the benchmark to which the Hospital is compared. Click other column headers to change the comparison.

  WellSpan Ephrata Community Hospital PA Rate US Rate COC Standard
Radiation therapy is administered within one year for women receiving breast conserving surgery for breast cancer      95.5% 94.7% 92.4% 90.0%
Combination chemotherapy is considered or administered within 4 months of diagnosis for women with hormone-receptor negative breast cancer      100.0% 94.6% 93.3% 90.0%
Tamoxifen (or equivalent drug therapy) is considered or administered within one year for women with hormone-receptor positive breast cancer      100.0% 96.3% 93.2% 90.0%
At least 12 regional lymph nodes are removed and examined for colon cancer patients who have had colon surgery      87.5% 92.6% 92.2% 80.0%
Chemotherapy is considered or administered within 4 months of diagnosis for patients with (lymph node positive) colon cancer      N/A 91.1% 89.3% 90.0%

Stroke

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.

  WellSpan Ephrata Community Hospital PA Rate US Rate Top 10% Nationally
Blood Clot Prevention      98% 98% 97% 100%
Discharged on Medication to Prevent Complications      99% 100% 99% 100%
Stroke Patients with Irregular Heartbeat Prescribed Blood Thinner      90% 98% 97% 100%
Clot Buster Given within 3 Hours of Symptoms      N/A 91% 88% 100%
Prescribed Medicine to Prevent Complications within 2 Days of Arrival      100% 99% 98% 100%
Discharged on Statin      95% 98% 97% 100%
Stroke Education      98% 95% 95% 100%
Assessed for Rehabilitation      100% 99% 98% 100%

Outcome Measures Measures hospital results in specific areas.

  WellSpan Ephrata Community Hospital PA Average    
30-Day Death Rate for Stroke Patients      14.0 % 14.0 % 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.

  WellSpan Ephrata Community Hospital PA Rate US Rate Top 10% Nationally
Beta Blocker during the Perioperative Period      96% 99% 98% 100%
Prophylactic Antibiotic within 1 hour of incision      [ + ] 100% 99% 99% 100%
Appropriate Antibiotic      [ + ] 100% 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      99% 99% 98% 100%
Surgery Patients with Perioperative Temperature Management      N/A 100% 100% 100%
VTE Ordered prior to Surgery      100% 99% 98% 100%
VTE Received within 24 Hours of Surgery      100% 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.

  WellSpan Ephrata Community Hospital PA Rate US Rate Top 10% Nationally
Blood Clot Prevention      99% 96% 94% 100%
ICU Blood Clot Prevention      99% 98% 97% 100%
Appropriate Blood Clot Treatment Using Two Blood Thinners      93% 94% 94% 100%
Heparin with Platelet Count Monitoring      100% 100% 99% 100%
Warfarin Discharge Instructions      100% 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.

  WellSpan Ephrata Community Hospital PA Avg US Avg Top 10% Nationally
Doctor Communication      76% 81% 82% 89%
Nurse Communication      77% 81% 80% 87%
Responsiveness of Hospital Staff      63% 68% 70% 82%
Pain Well Controlled      62% 71% 71% 78%
Medicine Explained by Staff      57% 64% 66% 74%
Room and Bathroom Kept Clean      67% 74% 75% 85%
Room Quiet at Night      45% 55% 62% 75%
Provided Discharge Information      91% 88% 87% 92%
Care Transition      48% 52% 53% 61%
Hospital Rating      61% 71% 73% 84%
Hospital Recommendation      61% 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.

  WellSpan Ephrata Community Hospital PA Rate US Rate Top 10% Nationally
Pnuemococcal Immunization      98% 92% 92% 99%
Influenza Immunization      99% 94% 93% 100%
Flu Vaccine for Health Care Workers      96% 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.

  WellSpan Ephrata Community Hospital PA Average US Average  
Time from Emergency Department (ED) Arrival to ED Departure for Admitted Patients      345 Minutes 280 Minutes 281 Minutes  
Time from Admit Decision to Departure Time from the Emergency Department (ED) for Admitted Patients      97 Minutes 110 Minutes 102 Minutes  
Median Time From ED Arrival to ED Departure for Discharged ED Patients      224 Minutes 143 Minutes 140 Minutes  
Door to Diagnostic Evaluation by a Qualified Medical Professional      50 Minutes 21 Minutes 20 Minutes  
ED-Median Time to Pain Management for Long Bone Fracture      62 Minutes 54 Minutes 48 Minutes  
ED-Patient Left Without Being Seen      2% 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.