Clinical Quality

Main Content

Our Quality Measures

Hand Hygiene and Hospital-Acquired Infections

A robust hand hygiene program (HH) is the major driver for eliminating hospital-acquired infections (HAI). UMMC made reduction of HAIs a primary quality improvement goal, and as shown in the graphic (access the graph in the link below) these have fallen by over 60% in the past four years. The sustained improvement in HH in this graph, combined with standardizing other infection prevention practices are the mainstays of this program as we drive to achieve zero HAIs.

Patient Safety Reporting

UMMC is focused on improving patient safety. This is accomplished by encouraging the staff and providers to report events such as: unexpected outcomes, patient safety issues, and good catch occurrences. The goal is to increase reporting. The reports are then reviewed by a content expert within seven days. The goal is to take a non-punitive approach to the investigation and implement process changes to prevent future events from occurring. The graph below shows i. UMMC’s patient safety reporting continues at a high level, apart from a drop during the COVID pandemic, and ii. Reviews in less than seven days approaches the target of 80%.

30-Day Readmissions

This measure is used by the Centers for Medicare and Medicaid Services (CMS) to assess the quality of care transitions for patients discharged from the hospital. It is publicly reported and used to reduce payment to hospitals with readmission rates above the national mean. UMMC’s reported 30-day readmission rates are right at the national mean. Data over the past two years show that the population identified with criteria for diabetes have a 5% higher rate of readmission than those without such criteria as shown in the graph. Current work is focused on improving care transitions for this population.

Hospital Mortality

Deaths in the hospital are tracked as an Observed: Expected (O:E) Mortality ratio. This ratio compares how many patients actually die in the hospital with the average number of deaths that would have been expected for patients with a particular illness or condition. This ratio is benchmarked against all other academic medical centers by an external vendor and is reported in this figure. The UMMC O:E ratio remains greater than one (the target is to be less than one). Improvement work is focused on: i. a standard process for reviewing all deaths, and ii. Improving documentation of disease severity which influences expected mortality.

Patient Experience

All hospitals are required to survey their discharged patients using a national standardized survey administered by independent vendors. There are 10 domains to the hospital survey primarily around communication with patients and family. The data are published on Hospital Compare and used in both reputation scorecards and pay-for-performance programs. UMMC scorecard reports the overall hospital rating by patients as our main patient experience measure. Our overall rating had improved by January 2020, but had a major fall at the beginning of the COVID pandemic.