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Frequently Asked Questions

1. What will I find in this Quality Report?

This Quality Report shares FLORIDA HOSPITAL Fish Memorial’s clinical results (such as complication rates or number of procedures performed) and our patient satisfaction results.

The data is displayed as follows:
  1. Numbers, called "indicators," such as the percentage of patients who experienced a complication; and
  2. Descriptions of our progress toward nationally recommended safe practices, such as our “Speak Up” communication program and administration of medications.

We rate our performance as follows:
  • Indicators that are percentages or ratios. If national data are available for an indicator, we compare Fish Memorial’s performance to the national average and color-code our results. A “green” rating means we exceeded the national average; a yellow rating means we’re near the national average; and a red rating means we’re below than the national average. We use standard statistical procedures to determine which code to use, with a variation range of +/-5% on either side of the indicator.
  • Pop-ups. Throughout this report, you can activate links and "pop-up" boxes by pointing and clicking on them with your mouse. For example, by clicking on an indicator description or column symbol, you can open a data box that gives you an additional explanation.
Unless you click on the data and ratings for additional details, you will see an incomplete picture of our performance.

2. How did FLORIDA HOSPITAL Fish Memorial select these quality indicators and safe practices?

National organizations have endorsed lists of quality indicators and safe practices. All the indicators or safe practices have extensive research to support their use and are defined so that all hospitals, including FLORIDA HOSPITAL Fish Memorial, can use the same method for calculating statistics. You can view this publicly available data at the following websites:
Indicators and safe practices are not perfect, however. We don’t agree that all the items we report are valid assessments of important quality issues. Even for such items, however, we use the national definition and report our performance. This full reporting assures you that FLORIDA HOSPITAL Fish Memorial does not selectively report only our strengths.

3. Does this Quality Report display data about individual physicians?

No. The report publishes hospital-based data only. This hospital performance data is current and already available to the public on the third party websites of the CMS, AHCA and HCAPHS.  The current data provides a picture that is approximately six to 12 months more recent than what is available on those organizations’ websites. By viewing the Quality Report, you’re guaranteed the latest information on FLORIDA HOSPITAL Fish Memorial’s quality performance.

4. Why does FLORIDA HOSPITAL Fish Memorial publish its quality data?

As a hospital that continuously strives to improve the patient experience, we like what quality data reporting does for you, the health care consumer. As a not-for-profit health care system and a community resource, FLORIDA HOSPITAL Fish Memorial believes that you deserve to know how we are performing. We want patients and their families to have access to up to date information about the quality of Florida’s health care.

We like what quality data reporting does for FLORIDA HOSPITAL Fish Memorial. Public reporting helps us document our care more carefully; obtain more accurate data and creates a corporate culture committed to accountability and ongoing improvement.

We also like what open reporting does for hospital care in general. We hope that our quality reporting provides our staff with a better understanding of how to assess, report and improve the hospital’s quality of care.

5. What does it mean if a hospital's performance indicator is red?

There are many possible reasons a performance indicator might be red.

Here are a few:
  • The hospital may provide care that is lower than the national average. About half the hospitals in the United States are less than average on any given indicator. Even performance that is significantly worse than the national average may still be well within the range of good care.  
  • The hospital may do a better job than other hospitals of detecting and reporting infections or complications.  
  • The hospital may do a poorer job than other hospitals of detecting and reporting risk factors. Therefore, that hospital would not get full credit for the complexity of its cases.  
  • The indicator may present an incomplete picture of what is being measured.
  • Insufficient or incomplete indicators include those based only on the number of procedures and those based on billing data.
  • The indicator's risk adjustment statistical model may not evaluate every factor; therefore, a hospital may not receive full credit for the complexity of its cases.  
  • The hospital may be doing a poor job and needs to improve.
FLORIDA HOSPITAL Fish Memorial is committed to creating action plans to address any performance indicator that isn’t meeting our goals.

6. How often is this report updated?

At the minimum, this report is updated quarterly as new data become available.