Delivering the Right Care

At Massachusetts General Hospital, we fully support the nationwide effort to ensure that patients coming into the hospital with specific conditions receive recommended care. These recommendations are based on years of research on interventions that have been proven to improve outcomes for these conditions. To view the MGH’s performance on these measures by race, go to Providing Equitable Care.

Click on any of the measure names below to see a detailed description of the measure, our performance over time and what we are doing to improve. On the chart below, hover your mouse over the data columns or icons to see more information.

Measure	Our Current Performance	Comparison Group	How We Compare
Heart Attack
Aspirin at Arrival	99% Jan-Mar 2009 data.	100% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH's current performance is below the Joint Commission 90th percentile but above the national average of 98%.
Aspirin at Discharge	100% Jan-March 2009 data.	100% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH has achieved the best possible performance.
ACE-I/ARB at Discharge (AMI)	100% Jan-March 2009 data. Note: Low volume-only 7 eligible cases.	100% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	The number of cases this quarter is too small to draw conclusions about performance.
Beta Blocker at Discharge	99% Jan-March 2009 data.	100% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH's current performance is below the Joint Commission 90th percentile but above the national average of 98%.
Smoking Counseling (AMI)	100% Jan-March 2009 data.	100% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH has achieved the best possible performance.
Time to Primary PCI of Less Than or Equal to 90 Minutes	72% Jan-March 2009 data. Note: Low volume-only 18 eligible cases.	97% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	The number of cases this quarter is too small to draw conclusions about performance. “Time is Muscle:” Reducing Door to Balloon Time Can Save Lives of Heart Attack Patients
Measure	Our Current Performance	Comparison Group	How We Compare
Heart Failure
ACE-I/ARB at Discharge (HF)	93% Jan-March 2009 data.	100% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH's current performance is below the Joint Commission 90th percentile but equal to the national average of 93%.
Discharge Instructions (HF)	89% Jan-March 2009 data.	99% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH's current performance is below the Joint Commission 90th percentile but is above the national average of 83%.
LVF Assessment	100% Jan-March 2009 data.	100% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH has achieved the best possible performance.
Smoking Counseling (HF)	100% Jan-March 2009 data.	100% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH has achieved the best possible performance.
Measure	Our Current Performance	Comparison Group	How We Compare
Pneumonia
Antibiotics within 6 hours	92% Jan-March 2009 data.	99% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH's current performance is below the Joint Commission national average of 94%.
Pneumovax Vaccination	89% Jan-March 2009 data.	99% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH's current performance is below the Joint Commission 90th percentile but equal to the national average of 89%.
Selection of Antibiotics	100% Jan-March 2009 data.	99% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH has achieved the best possible performance.
Smoking Counseling (PN)	100% Jan-March 2009 data.	100% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH has achieved the best possible performance.
Timing of Blood Cultures	100% Jan-March 2009 data.	99% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH has achieved the best possible performance.
Measure	Our Current Performance	Comparison Group	How We Compare
Surgery
Antibiotics Received One Hour Prior to Surgery	98% Jan-March 2009 data.	98% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH's current performance is the same as the Joint Commission 90th percentile and above the national average of 93%.
Antibiotic Selection for Surgical Cases	99% Jan-March 2009 data.	99% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH's current performance is the same as the Joint Commission 90th percentile and above the national average of 97%.
Antibiotics Discontinued 24 Hours after Surgery	96% Jan-March 2009 data.	100% The 90th percentile of Joint Commission (TJC) accredited hospitals. Benchmark is based on Jan-Dec 08 data.	MGH's current performance is below the Joint Commission 90th percentile but above the national average of 90%.
Measure	Our Current Performance	Comparison Group	How We Compare
Smoking Counseling
Smoking Counseling: A Composite Measure for Heart Attack, Heart Failure, and Pneumonia	100% Jan-March 2009 data.	100% University HealthSystem Consortium (UHC) benchmark based on rolling 4 quarters of data.	MGH has achieved the best possible performance.
Measure	Our Current Performance	Comparison Group	How We Compare
Leapfrog Evidence Based Hospital Referrals
Heart Bypass Surgery (CABG)	452 MGH's annual procedure volume reported on 2009 survey.	450 Recommended annual procedure volume for hospitals by the Leapfrog group.	MGH exceeds the recommended annual procedure volume set by the Leapfrog group.
Heart Angioplasty (PCI)	1231 MGH's annual procedure volume reported on 2009 survey.	400 Recommended annual procedure volume for hospitals by the Leapfrog group.	MGH exceeds the recommended annual procedure volume set by the Leapfrog group.
Abdominal Aortic Aneurysm (AAA) repair	212 MGH's annual procedure volume reported on 2009 survey.	50 Recommended annual procedure volume for hospitals by the Leapfrog group.	MGH exceeds the recommended annual procedure volume set by the Leapfrog group.
Aortic Valve Replacement	337 MGH's annual procedure volume reported on 2009 survey.	120 Recommended annual procedure volume for hospitals by the Leapfrog group.	MGH exceeds the recommended annual procedure volume set by the Leapfrog group.
Esophageal Resection	59 MGH's annual procedure volume reported on 2009 survey.	13 Recommended annual procedure volume for hospitals by the Leapfrog group.	MGH exceeds the recommended annual procedure volume set by the Leapfrog group.
Pancreatic Resection	95 MGH's annual procedure volume reported on 2009 survey.	11 Recommended annual procedure volume for hospitals by the Leapfrog group.	MGH exceeds the recommended annual procedure volume set by the Leapfrog group.
Bariatric Surgery	130 MGH's annual procedure volume reported on 2009 survey.	125 Recommended annual procedure volume for hospitals by the Leapfrog group.	MGH exceeds the recommended annual procedure volume set by the Leapfrog group.
High-risk Delivery	57 Number of very low birth weight (VLBW) cases reported on MGH's 2009 survey.	50 Recommended annual volume of VLBW cases for hospitals by the Leapfrog group.	MGH exceeds the recommended annual volume of VLBW cases set by the Leapfrog group.
Measure	Our Current Performance	Comparison Group	How We Compare
Leapfrog Common Acute Conditions
Heart Attack	Substantial progress Based on 2009 survey submission.	Fully meets standard Highest rating given by the Leapfrog group.	MGH has made substantial progress on this Leap.
Pneumonia	Substantial progress Based on 2009 survey submisison.	Fully meets standard Highest rating given by the Leapfrog group.	MGH has made substantial progress on this Leap.
Normal Deliveries	Fully meets standard Based on 2009 survey submission.	Fully meets standard Highest rating given by the Leapfrog group.	MGH has achieved the best possible rating by the Leapfrog group.

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