Holy Family Hospital - Methuen Methuen, Ma Reviews

Preparing your results. Please wait.

Preventing and Responding to Patient Harm

Mensurate proper name	Leapfrog's Standard	Hospital's Progress
Constructive Leadership to Forestall Errors	Hospitals should take meaningful steps to raise awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resources to implement a patient safety program, and develop systems and structures to support action to amend patient safety. more	ACHIEVED THE STANDARD
	Evidence more than on this hospital's performance Prove less This hospital scored 120.00 out of 120.00 possible points.
Staff Work Together to Forestall Errors	Hospitals should assess their civilization of safety and hold leadership accountable for implementing policies, procedures, and staff education to amend the civilisation of rubber. more	Accomplished THE STANDARD
	Show more on this infirmary'south performance Prove less This hospital scored 120.00 out of 120.00 possible points.
Back up for Nursing Workforce	Hospitals should assess their nursing staff levels and core competencies, included nurses in leadership, and develop and implement plans to address any areas of improvement. more	ACHIEVED THE STANDARD
	Show more on this infirmary's performance Show less This infirmary scored 100.00 out of 100.00 possible points.
Handwashing	Hospitals should regularly monitor paw hygiene practices for everyone interacting with patients, and requite feedback to ensure compliance. Hospitals should foster a culture of good hand hygiene, offer preparation and instruction, and provide equipment, such as newspaper towels, soap dispensers, and hand sanitizer. more	ACHIEVED THE STANDARD
	Show more on this hospital's operation Show less Hand Hygiene Domain Performance Hospital regularly monitors hand hygiene practices Met the monthly requirements for monitoring using direct ascertainment only. Feedback provided to ensure compliance with mitt hygiene Met Appropriate grooming and teaching provided Met Admission to paper towels, soap dispensers, and hand sanitizer maintained Met Civilization of good hand hygiene emphasized Met
Responding to Never Events	Hospitals should accept a never events policy that includes all nine (ix) actions that should occur post-obit a "never event," which includes apologizing to the patient and non charging for costs associated with the never outcome. more	ACHIEVED THE STANDARD

Medication Safety

Measure proper noun	Leapfrog'southward Standard	Hospital'southward Progress
Safe Medication Administration	Hospitals should have nurses and other clinicians utilise BCMA in all medical/surgical units, intensive care units, and labor and delivery units to scan the patient and medication prior to administration at least 95% of the time. The BCMA system includes decision support to prevent errors and the infirmary has processes to prevent workarounds. more	ACHIEVED THE STANDARD
	Show more than on this hospital's functioning Show less Implementation Performance The extent of BCMA implementation throughout the infirmary with a focus on medical and/or surgical units (developed and pediatric), labor and delivery units, and intensive intendance units (adult, pediatric, and neonatal) 100% Compliance with both patient and medication scans at the bedside prior to administering medications 95% The types of decision back up that the BCMA system offers 5 out of five Structures to monitor and reduce workarounds 8 out of 8
Safe Medication Ordering	Hospitals should enter at to the lowest degree 85% of inpatient medication orders through the CPOE system. more than	ACHIEVED THE STANDARD
	Show more than on this infirmary'due south performance Bear witness less This hospital'south pct of inpatient medication orders entered electronically: 75-84% This hospital's score on the CPOE Evaluation Tool: Full Demonstration of National Safety Standard for Determination Support
Medication Reconciliation	Hospitals should have a rate of unintentional medication discrepancies per medication that is lower than or equal to the 50th percentile (where lower operation is better) nationally. more	SOME ACHIEVEMENT
	Show more on this hospital's performance Evidence less This infirmary's rate of unintentional discrepancies per medication is: 0.224
Medication Documentation for Elective Outpatient Surgery Patients	Hospitals should certificate 90% or more of abode medications, visit medications, and allergies/agin reaction(south) in the patients' clinical tape. more	Accomplished THE STANDARD
	Show more on this hospital'due south performance Evidence less Documentation Rate Medications the patient was taking at home 100% Medications the patient was administered and prescribed during their visit 100% Allergies and adverse reactions 97%

Healthcare Associated Infections

Measure proper noun	Leapfrog's Standard	Infirmary'south Progress
Infection in the Blood	Hospitals should have fewer than expected central-line associated blood stream infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than i means fewer infections than expected; a number more than than one means more infections than expected. more	Achieved THE STANDARD
	Show more than on this infirmary's performance Show less This infirmary'due south standardized infection ratio (SIR) is: 0.000 Notation: The standardized infection ratio (SIR) includes some data collected during the COVID-nineteen pandemic.
Infection in the Urinary Tract	Hospitals should have fewer than expected catheter-associated urinary tract infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than ane ways fewer infections than expected; a number more i ways more infections than expected. more than	LIMITED Accomplishment
	Show more on this hospital'south performance Show less This infirmary's standardized infection ratio (SIR) is: 3.337 Note: The standardized infection ratio (SIR) includes some data collected during the COVID-xix pandemic.
C. difficile Infection	Hospitals should take fewer than expected colon infections from C. diff bacteria. Leapfrog uses a standardized infection ratio (SIR) calculated past the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that really happened at this hospital to the number of infections expected for this infirmary, given various factors. A number lower than one means fewer infections than expected; a number more one means more than infections than expected. more	Accomplished THE STANDARD
	Show more on this hospital'southward performance Show less This infirmary's standardized infection ratio (SIR) is: 0.551 Note: The standardized infection ratio (SIR) includes some data nerveless during the COVID-19 pandemic.
MRSA Infection	Hospitals should have fewer than expected antibiotic resistant bacterial infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC'due south National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than than one ways more than infections than expected. more	Express Achievement
	Show more on this hospital'south performance Bear witness less This hospital's standardized infection ratio (SIR) is: 1.957 Annotation: The standardized infection ratio (SIR) includes some information collected during the COVID-19 pandemic.
Surgical Site Infection After Colon Surgery	Hospitals should have fewer than expected surgical site infections after major colon surgery. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. more than	Accomplished THE STANDARD
	Bear witness more on this hospital's performance Show less This hospital'due south standardized infection ratio (SIR) is: 0.000 Note: The standardized infection ratio (SIR) includes some information nerveless during the COVID-nineteen pandemic.

Maternity Care

Measure proper noun	Leapfrog'south Standard	Hospital's Progress
Cesarean Sections	This is defined as first-time mothers giving birth to a single infant, at total-term, in the head-down position deliver their babies through a C-section. Hospitals should have a charge per unit of C-sections of 23.6% or less. more	Express Achievement
	Show more on this infirmary's operation Show less This hospital'southward charge per unit of Cesarean sections is34.four%
Early Constituent Deliveries	This is divers every bit mothers existence scheduled for cesarean sections or medication inductions prior to 39 weeks gestation without a medical reason. Hospitals should have a rate of early on elective deliveries of 5% or less. more than	ACHIEVED THE STANDARD
	Show more on this infirmary'south functioning Show less This hospital'southward rate of early on elective deliveries is0.0%
Episiotomies	This is divers as mothers having an incision made in the perineum (the birth culvert) during childbirth. Hospitals should take a rate of episiotomies of 5% or less. more	Accomplished THE STANDARD
	Show more on this hospital's operation Show less This infirmary'southward rate of episiotomies is4.i%
Screening Newborns for Jaundice Before Discharge	Hospitals should screen at to the lowest degree 90% of babies for jaundice. more than	ACHIEVED THE STANDARD
	Show more on this hospital's performance Show less This hospital's rate of screening newborns for jaundice before discharge is92.7%
Preventing Claret Clots in Women Undergoing Cesarean Section	At least 90% of women undergoing a cesarean department receive treatment to forestall blood clots. more	ACHIEVED THE STANDARD
	Testify more on this hospital's performance Show less This hospital's charge per unit of preventing blood clots in women undergoing cesarean section94.6%
Loftier-Risk Deliveries	Hospitals should evangelize at least 50 very-depression birth weight babies per yr OR the infirmary must maintain a lower-than-average morbidity/bloodshed rate for very-low birth weight babies. more	DOES NOT Apply

More Data

Number of Live Births

The hospital had1,013 live births (i.e., liveborn infants) at this infirmary location for the reporting fourth dimension period.

Pediatric Care

Mensurate name	Leapfrog's Standard	Hospital's Progress
Experience of Children and Their Parents	Hospitals should perform better than virtually hospitals in v (5) areas: Communication with Parent – Communication about your child's medicines Advice with Parent – Keeping you lot informed about your kid's care Communication with Child – How well nurses communicate with your child Communication with Child – How well doctors communicate with your child Attention to Condom and Comfort – Preventing mistakes and helping you report concerns. more	DOES NOT Apply
	Show more than on this hospital's performance Evidence less This hospital does not admit pediatric patients or had besides few pediatric admissions to administrate the patient experience survey.
Radiation Dose for Abdomen/Pelvis Scans	Hospitals should apply a CT radiation dose for routine CT scans of the abdomen and pelvis that falls within national benchmarks. more	Limited Achievement
Radiation Dose for Head Scans	Hospitals should have an average radiations dose for routine CT scans of the caput that falls within national benchmarks. more	CONSIDERABLE Accomplishment

Critical Intendance

Measure out name	Leapfrog'due south Standard	Infirmary's Progress
Peculiarly Trained Doctors Care for Disquisitional Care Patients	Hospitals should have intensivists present on-site at least viii hours a twenty-four hours, vii days per week or has intensivists present via 24/vii telemedicine with some on-site intensivist presence. When non in the ICU, the intensivist immediately responds to calls and has some other physician or trained clinician who can immediately reach the patient. more than	ACHIEVED THE STANDARD
	Show more on this hospital'south operation Show less This hospital achieved the standard using on-site intensivist coverage.

Complex Adult and Pediatric Surgery

Measure name	Leapfrog'southward Standard	Hospital's Progress
Carotid Artery Surgery	Hospitals should perform at least xx procedures annually, and as part of their procedure for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. more	ACHIEVED THE STANDARD
	Prove more on this hospital's performance Show less This hospital performed 28 carotid avenue surgeries compared to Leapfrog'due south standard of xx procedures annually. As part of their procedure for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog's minimum surgeon volume standard of at least 10 procedures annually for carotid artery surgery. Additionally, this infirmary does not have protocols in identify to ensure that carotid artery surgeries are only performed on patients that come across divers criteria.
Mitral Valve Repair and Replacement	Hospitals should perform at least 40 procedures annually, and equally part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. In addition, hospitals should participate in a national clinical registry and achieve the aforementioned or better outcomes when compared to others who also perform this procedure. more	DOES Not Utilize
Open Aortic Procedures	Hospitals should perform at least ten procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. more	SOME Achievement
	Evidence more on this hospital'southward operation Evidence less This hospital performed 5 open aortic procedures compared to Leapfrog's standard of 10 procedures annually. Every bit part of their procedure for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog'southward minimum surgeon book standard of at to the lowest degree 7 procedures annually for open aortic procedures. Additionally, this hospital does not have protocols in identify to ensure that open up aortic procedures are only performed on patients that see defined criteria.
Bariatric Surgery for Weight Loss	Hospitals should perform at least l procedures annually, and as role of their process for privileging surgeons, ensure that each surgeon performs at to the lowest degree xx procedures annually. more	DOES Not APPLY
Esophageal Resection for Cancer	Hospitals should perform at least twenty procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least seven procedures annually. more	DOES Not APPLY
Lung Resection for Cancer	Hospitals should perform at least 40 procedures annually, and as part of their procedure for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually. more	SOME Accomplishment
	Show more than on this hospital's operation Prove less This hospital performed 17 lung resections for cancer compared to Leapfrog'southward standard of 40 procedures annually. As part of their procedure for privileging surgeons, this infirmary does ensure that each surgeon meets or exceeds Leapfrog'south minimum surgeon volume standard of at least 15 procedures annually for lung resection for cancer. Additionally, this hospital does indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that lung resections for cancer are but performed on patients that run across divers criteria.
Pancreatic Resection for Cancer	The hospital performs at least 20 procedures annually, and as part of their process for privileging surgeons, ensures that each surgeon performs at least 10 procedures annually. more	DOES NOT APPLY
Rectal Cancer Surgery	Hospitals should perform at least 16 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at to the lowest degree 6 procedures annually. more	SOME ACHIEVEMENT
	Evidence more on this hospital's performance Testify less This hospital performed ane rectal cancer surgeries compared to Leapfrog's standard of 16 procedures annually. As part of their process for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog's minimum surgeon book standard of at least six procedures annually for rectal cancer surgery. Additionally, this hospital does point having national accreditation from the American College of Surgeons or a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that rectal cancer surgery is only performed on patients that meet divers criteria.
Total Hip Replacement Surgery	Hospitals should perform at least l procedures annually, and as office of their procedure for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	Accomplished THE STANDARD
	Evidence more than on this hospital'south performance Show less This hospital performed 214 total hip replacement surgeries compared to Leapfrog'southward standard of fifty procedures annually. As part of their procedure for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog's minimum surgeon book standard of at least 25 procedures annually for total hip replacement surgeries. Additionally, this hospital does have protocols in place to ensure that total hip replacement surgery is only performed on patients that see defined criteria.
Total Knee Replacement Surgery	Hospitals should perform at least l procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more than	Accomplished THE STANDARD
	Show more than on this hospital's performance Show less This hospital performed 277 total genu replacement surgeries compared to Leapfrog'southward standard of 50 procedures annually. As role of their procedure for privileging surgeons, this hospital does ensure that each surgeon meets or exceeds Leapfrog's minimum surgeon volume standard of at least 25 procedures annually for total knee replacement surgeries. Additionally, this hospital does have protocols in identify to ensure that full knee replacement surgery is merely performed on patients that run across defined criteria.
Congenital Heart Surgery for Infants (Norwood Procedure)	Hospitals should perform at to the lowest degree viii procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least v procedures annually. more than	DOES Non APPLY

Elective Outpatient Surgery - Adult

Dermatology (Skin)

Procedure		Number of Procedures Performed Annually
Circuitous Skin Repairs		61

Gastroenterology (Breadbasket and Digestive)

This hospital performs these procedures at:

• Holy Family unit Hospital - Methuen, Methuen
• Andover Surgery Eye, Andover

Process		Number of Procedures Performed Annually
Upper GI Endoscopies		954
Other Upper GI Procedures		0
Pocket-size Intestine and Stomal Endoscopies		5
Lower GI Endoscopies		ane,223

General Surgery

This infirmary performs these procedures at:

• Holy Family Hospital - Methuen, Methuen
• Andover Surgery Center, Andover

Process		Number of Procedures Performed Annually
Cholecystectomies and Common Duct Explorations		145
Hemorrhoid Procedures		36
Inguinal and Femoral Hernia Repairs		128
Laparoscopies		xiv
Lumpectomies and Quadrantectomies of Breast		113
Mastectomies		fifteen
Other Hernia Repairs		87

Neurosurgery

Procedure		Number of Procedures Performed Annually
Spinal Fusion Procedures		thirteen

Obstetrics and Gynecology

Procedure		Number of Procedures Performed Annually
Cervix Procedures		12
Hysteroscopies		155
Uterus and Adnexa Laparoscopies		68

Ophthalmology (Eyes)

This hospital performs these procedures at:

• Andover Surgery Center, Andover

Procedure		Number of Procedures Performed Annually
Anterior Segment Center Procedures		206
Posterior Segment Eye Procedures		0
Other Eye Procedures		152

Orthopedic (Bones and Joints)

This hospital performs these procedures at:

• Holy Family Hospital - Methuen, Methuen
• Andover Surgery Middle, Andover

Process		Number of Procedures Performed Annually
Finger, Hand, Wrist, Forearm, and Elbow Procedures		369
General Orthopedic Procedures		35
Hip Procedures		one
Knee Procedures		172
Shoulder Procedures		125
Spine Procedures		136
Toe, Foot, Talocrural joint, and Leg Procedures		88

Otolaryngology (Ear, Olfactory organ, Mouth, and Throat)

This hospital performs these procedures at:

• Holy Family Hospital - Methuen, Methuen
• Andover Surgery Center, Andover

Procedure		Number of Procedures Performed Annually
Ear Procedures		43
Oral cavity Procedures		14
Nasal and Sinus Procedures		140

Plastic and Reconstructive Surgery

Procedure		Number of Procedures Performed Annually
Breast Repairs or Reconstructions		18
Skin Grafts and Repairs		173

Urology (Urinary Tract, Male Reproductive)

This hospital performs these procedures at:

• Holy Family Hospital - Methuen, Methuen
• Andover Surgery Center, Andover

Procedure		Number of Procedures Performed Annually
Circumcisions		27
Cystourethroscopies		410
Male Genital Procedures		20
Urethra Procedures		26
Vaginal Repair Procedures		9

Elective Outpatient Surgery - Pediatric

Gastroenterology (Stomach and Digestive)

This hospital performs these procedures at:

• Holy Family Infirmary - Methuen, Methuen
• Andover Surgery Center, Andover

Procedure		Number of Procedures Performed Annually
Lower GI Endoscopies		1
Other Upper GI Procedures		0
Small Intestine and Stomal Endoscopies		0
Upper GI Endoscopies		i

General Surgery

This infirmary performs these procedures at:

• Holy Family Hospital - Methuen, Methuen
• Andover Surgery Center, Andover

Procedure		Number of Procedures Performed Annually
Inguinal and Femoral Hernia Repairs		0
Other Hernia Repairs		1

Orthopedic (Bones and Joints)

This infirmary performs these procedures at:

• Holy Family Hospital - Methuen, Methuen
• Andover Surgery Center, Andover

Procedure		Number of Procedures Performed Annually
Finger, Hand, Wrist, Forearm, and Elbow Procedures		67
Full general Orthopedic Procedures		4
Hip Procedures		0
Knee joint Procedures		6
Shoulder Procedures		6
Spine Procedures		0
Toe, Foot, Ankle, and Leg Procedures		4

Otolaryngology (Ear, Nose, Rima oris, and Throat)

This hospital performs these procedures at:

• Holy Family unit Hospital - Methuen, Methuen
• Andover Surgery Center, Andover

Procedure		Number of Procedures Performed Annually
Ear Procedures		22
Mouth Procedures		0
Nasal and Sinus Procedures		iv
Pharynx, Adenoid, and Tonsil Procedures		iii

Urology (Urinary Tract, Male person Reproductive)

This hospital performs these procedures at:

• Holy Family Hospital - Methuen, Methuen
• Andover Surgery Center, Andover

Procedure		Number of Procedures Performed Annually
Cystourethroscopies		two
Male Genital Procedures		6
Urethra Procedures		two
Vaginal Repair Procedures		0

Intendance for Elective Outpatient Surgery Patients

Measure name	Leapfrog'south Standard	Infirmary'due south Progress
Constituent Outpatient Surgery Recovery Staffing - Adult	Hospitals should ensure that a specially certified clinician and at least one md or nurse anesthetist are present and immediately available while an developed patient is present until discharge. more	ACHIEVED THE STANDARD
Elective Outpatient Surgery Recovery Staffing - Pediatric	Hospitals should ensure that a specially certified clinician and at least one dr. or nurse anesthetist are present and immediately available while a pediatric patient is present until discharge. more than	ACHIEVED THE STANDARD
Safe Surgery Checklist - Elective Outpatient Surgery	Hospitals should go through all the elements of a complete rubber surgery checklist on all patients every time a process is performed. more	Achieved THE STANDARD
Feel of Patients Undergoing Elective Outpatient Surgery	Hospitals should perform better than most on four (4) areas including: (a) facilities and staff (b) communication about the procedure, (c) patients' overall rating of the facility, and (d) patients willingness to recommend the facility. more	Express ACHIEVEMENT
	Evidence more than on this hospital's functioning Evidence less Performance on the following four domains of the Outpatient and Ambulatory Surgery (OAS) CAHPS Survey brand up a hospital'southward score on Leapfrog's "Experience of Patients Undergoing Elective Outpatient Surgery" measure. "Top Box Score" represents the percentage of respondents who gave the most favorable response. OAS CAHPS Survey Domain Top Box Score Facilities and staff 95% Advice about the process 92% Patients' overall rating of the facility 82% Patients willingness to recommend the facility 84%

More Data

Patient Consent for Constituent Outpatient Surgery	The infirmary provides written surgical consent forms the day of their procedure.
Patient Consent to Anesthesia for Elective Outpatient Surgery	The hospital provides written anesthesia consent forms the day of their procedure.
Patient Pick	The hospitalhas a screening protocol to determine whether a patient'due south procedure tin safely be performed on an outpatient basis, and the protocol includes the following components: History of hard intubation Yes Hard airway/aspiration hazard Yes Body Mass Index (BMI) Yes American Society of Anesthesiologists (ASA) Physical Status Nomenclature Yes Recent Medical History (within 30 days of scheduled procedure) Aye Cognitive Assessment Yes Sleep Apnea Assessment Yes Availability of transportation following discharge Yes Availability of a caregiver following discharge Yes

Holy Family unit Hospital - Methuen

seventy East Street
Methuen, Massachusetts 01844

kenyonmeme1977.blogspot.com

Source: https://ratings.leapfroggroup.org/facility/details/22-0080/holy-family-hospital---methuen-methuen-ma

Share :