Quality Report Card FAQs

1. What is this Quality Report Card?

It is an online tool that you can use to learn how well our hospitals cared for patients with certain common medical conditions and surgical procedures, and how our performance compared to hospitals around the country and the state. We believe that providing you with accurate information will help you become more involved in your health care.

We tried to simplify, as best as we can, the quality data on our Web pages to help you better understand the information. Also, whenever possible, we included consumer-friendly health information to help educate you about quality measures and why they are important.

There may be some measures that ranked significantly lower than the national average, and we are working hard to improve those with a "best practice" approach in which we share expertise from around the BayCare system. For these measures, we will provide you with an "Improvement Plan" to let you know what we are doing to help ensure that our scores improve in the future.

Our quality program also includes the internationally-recognized Six Sigma methodology, which helps us improve our clinical and operational performance by providing a formal process of quality training and education, evaluation and reporting.

Please be aware that this is a work-in-progress. We will be making improvements and additions to this online Quality Report Card as the national data that we are using for our foundation continues to grow. Use the information contained on these Web pages as a way to educate yourself about health conditions and treatments. Most importantly, talk to your health care provider about any questions you may have.

2. How did you decide if a hospital's score is significantly higher or significantly lower than the U.S. average?

We used an objective mathematical formula to determine whether the difference between our hospital score and the U.S. average score was statistically significant. This formula takes into account the total number of patients, or sample size, each hospital had for a particular quality measure. If the U.S. average fell within the range (or confidence interval) around the hospital’s score, then the difference was not statistically significant. The width of the range varies based on the total number of patients in the sample. The smaller the sample size, the wider the range. The larger the sample size, the narrower the range.

  • Hospital scores that were significantly higher than the U.S. average are highlighted in "Green."
  • Scores that were equal to or higher than the Top 10% of U.S. hospitals received a checkmark.
  • Scores that were significantly lower than the U.S. average are highlighted in "Red." For these measures, we provided an "Improvement Plan" to let you know what we plan to do to help ensure that our scores improve in the future.
  • Scores that were about the same as the U.S. average are highlighted in "Beige."

When planning our Quality Report Card, one of our main objectives was to create a tool that was easy to understand and easy to use. We believe public reporting will help us continue improving our tradition of high quality and innovation. While there is no single way to measure health care quality, the information in this online report is consistent with national reporting standards and methods. The Quality Report Card should be used by community members and patients to help them become more involved in their health care, in addition to talking with their doctor.

If you have any questions or feedback, we would appreciate hearing them. Please do not hesitate to send us an email.

3. Why did you decide to publicly display your quality data?

BayCare strives to have one of the best quality programs in the region. We are proud of our efforts and eager to share them. We believe that public reporting will help us strengthen our dedication to continuous quality improvement.

Our patients are at the center of our quality efforts. As such, we believe that providing accurate information about our hospitals in a simple, easy-to-use format, consistent with national data, will help our patients become more involved in their health care. The more you know, the better prepared you will be to ask the right questions for you and your family. We are proud to be the first in the Tampa Bay area to provide this kind of detailed information on our Web site. We take public reporting seriously and view it as an essential element of our commitment to the communities we serve.

4. How did you select which measures to include?

For now, the quality measures that we are using are the ones reported to the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission. The data shows how often our hospitals provided recommended care known to get the best results for most patients with certain common medical and surgical conditions. These indicators are already being reported on the CMS Web site, but we've made an effort to improve access and simplify the presentation for ease of use.

5. Will you include additional quality measures in the future?

Yes. This online report card is just a beginning for us. We plan to add more information on the site as the national data that we are using for our foundation continues to grow. We also have included a survey on the site asking users what additional types of measurements they would like to add down the road.

6. How often will you update the data on these web pages?

We plan on updating the data on our online Quality Report Card every quarter, or four times a year. We also plan on including more recent data and additional metrics in the future. Both will be consistent with widely-recognized quality definitions used for national reporting.

7. What do the colors and symbols mean?

We chose to use color-coded boxes and basic symbols to show our performance rankings. Our goal was to create a quick and easy-to-understand online tool that is interactive and user-friendly. Each table will have the key shown below, explaining the color coding and symbols.


Top Performance. At or above the U.S. Top 10 percent average.


Significantly higher than the U.S. average.


About the same as the U.S. average.


Significantly lower than the U.S. average. Hover over the cell to read our Improvement Plan.
* Technical Note: The sample size is too small (N<25) to apply significance testing.


No patients met the criteria for inclusion in the measure calculation.

8. If a hospital has a "Red" designation, does that mean the hospital does not provide quality care?

No. Statistics and data do not begin to tell the entire story of how a hospital performs. There is no standardized equation that will definitively tell you whether a hospital is good or bad. The majority of the time, our performance will be on par or better than the national average. However, there may be a handful of areas that we need to improve, and we are focused on a "best practice" approach in which we share expertise from around the BayCare system.

Please consult with your physician about any questions you may have about this information and how it can be used to make better decisions about your health.

9. One of the hospital scores has a yellow "Checkmark" icon indicating it was equal to the U.S. Top 10% score, but is not highlighted in "Green" which would mean the score was significantly higher than the U.S. average. How is that possible?

The "Green" color highlight is used when, based on an objective mathematical formula, the hospital score was determined to be significantly higher than the U.S. Average. However, we only applied the mathematical formula to scores that had a reasonable sample size (more than 25 patients or N>25), as identified by CMS. We also did not apply the significance tests in instances when the hospital’s score was exactly the same as the U.S. Top 10% score.

As a result, a score that has a yellow "Checkmark" icon but no "Green" color highlight means that either the particular score did not have a sufficient sample size to apply the statistical formula or the score was the same as the score of the U.S. Top 10% of hospitals.

10. If I have any questions about this online Quality Report Card, who can I contact?

We encourage you to contact us if you have any questions: email

You also can send a letter to:
Director Clinical Outcomes
BayCare Health System
2985 Drew Street
Clearwater, FL 33759

11. What is BayCare and where can I go for more information on BayCare's hospitals?

BayCare is a family of health care providers consisting of the leading not-for-profit hospitals in the Tampa Bay region. With more than 25,000 team members, 14 ambulatory centers and a wide array of other health services, we are the area's largest community-based health system.

Here is a list of our hospitals:

  • Bartow Regional Medical Center
  • BayCare Alliant Hospital
  • Mease Countryside Hospital 
  • Mease Dunedin Hospital 
  • Morton Plant Hospital 
  • Morton Plant North Bay Hospital 
  • St. Anthony's Hospital 
  • St. Joseph's Hospital 
  • St. Joseph's Hospital-North
  • St. Joseph's Hospital-South
  • St. Joseph's Children's Hospital 
  • St. Joseph's Women's Hospital 
  • South Florida Baptist Hospital
  • Winter Haven Hospital
  • Winter Haven Women's Hospital