Clinical Quality

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Our Quality Measures

Hospital-Acquired Infections

There are five types of hospital-acquired infections which must be reported to the Centers for Medicare and Medicaid Services (CMS). These are: i. blood stream infections associated with intravenous catheters in large, central veins; ii. infections associated with urinary catheters; iii. surgical site infections (after colon and hysterectomy surgery); iv. blood stream methicillin resistant staphylococcal infections (MRSA); v. clostridium difficile infections. These are reported on Hospital Compare as Standardized Infection Ratios. The UMMC scorecard reports the number of such infections each month. From January 2016 to December 2017, there has been a 43% reduction.

Patient Safety Indicators (PSIs)

PSIs are a set of measures that screen for adverse complications that patients can experience in a health care setting. Ten of these complications are reported to CMS and used in performance ranking and payment programs. These include occurrences such as collapsed lung, pressure ulcers, and blood clots in veins. These are considered largely preventable. They are reported on Hospital Compare as rates. The UMMC scorecard reports the number of these 10 complications per month.  There has been an 80% reduction in PSIs from January 2016 to December 2017.

30-Day Readmissions

This measure is used by CMS to assess the quality of care transitions for patients discharged from the hospital. The rate of readmission to any hospital for all patients and several select diagnostic groups, or disease categories, is publicly reported and used to reduce payment to hospitals with readmission rates above the national mean. The UMMC scorecard reports each month the readmission rate of all patients discharged from our hospital and readmitted to UMMC within 30 days. There has been no overall reduction from January 2016 through December 2017. The focus for 2018 is on patients with diabetes, who have a 5% higher 30-day readmission rate compared to patients without diabetes.

Hospital Mortality

Mortality rates are reported in different ways by different entities. CMS reports 30-day mortality for different diagnostic groups, or disease categories, for Medicare patients. For all patients admitted to our hospitals, UMMC’s scorecard reports risked-adjusted mortality – factoring in how sick a patient is – as an Observed:Expected 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, calculated by dividing the observed mortality by the expected mortality, is benchmarked against all other academic medical centers and managed by the University Healthsystem Consortium (Vizient). It is updated quarterly. UMMC has seen a modest (5%) reduction in the O:E ratio over 2016-17.

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 has improved by 45% from January 2016 to December 2017.