Quality and Safety Institute

Quality Outcomes

Mortality

Rochester Regional Health investigates and tracks several metrics related to mortality. After each patient death, a quality review is performed examining the severity of illness and to look for potential process opportunities Rates that are tracked include overall inpatient mortality and disease specific survival rates. Finally, hospitals evaluate their inpatient mortality rates by using an index value of observed mortality to expected mortality. 

  • Why is it important?

Measures related to mortality are important to track because they identify opportunities for improvement in care and care variation. Some illnesses have much lower expected mortalities rates than others, so if a patient expires from one of those unlikely causes, the Rochester Regional Health team wants to learn why to help improve future patient care. 


Falls

Inpatient falls are unplanned descents to the floor. They are avoidable events that have the potential to cause patient harm.

  • Why is it important?

Measures related to harm (including categorizing the potential injury related to patient falls) are important to track because they identify situations where patients could or actually experienced harm. Since these events are avoidable, understanding what a patient was doing at the time of the fall, whether or not the fall was observed, etc. provide insights to help prevent future harms. 

 


Healthcare-Associated Infections

Healthcare-associated infections (HAIs) are infections that a patient develops while in the hospital, related to the care received. Devices such as central lines and foley catheters, surgical procedures, and antibiotic use pose a risk of infection to the patient, so the use of them must balance the need for the device or procedure with the associated risk. HAIs are events that have the potential to cause significant patient harm. Catheter Associated Urinary Tract Infections (CAUTI), Central Line Associated Blood Stream Infections (CLABSI), Clostridium difficile (C.diff) infection, Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and Surgical Site Infections (SSIs) are important healthcare-associated infections that are routinely assessed and reported to state and federal agencies as required.

  • Why is it important?

HAIs are avoidable harms that occur in the healthcare setting. Patients who acquire HAIs have increased length of stay compared to those without HAIs, and have poorer outcomes. Preventing HAIs is the focus of the Infection Prevention Program.

 


Hand Hygiene

Hand hygiene is cleansing hands using either soap and water or alcohol hand rub. Hand hygiene is the single most effective way to prevent the spread of infection. Hand hygiene is performed during these 5 moments* of patient care:

5momentshandhygeine
  1. Before touching a patient
  2. Before a clean/aseptic procedure
  3. After blood/body fluid exposure
  4. After touching a patient
  5. After touching a patient's environment 

 

  • Why is it important?

Hand Hygiene is the most important action against spreading infection from person to person. 

* World Health Organization Five Moment of Hand Hygiene

 


Readmissions

Readmissions occur when a patient needs to come back to the hospital for an inpatient stay. Generally, hospitals track 30-day readmission rates for the overall hospital as well as disease specific conditions, but other readmission time frames can also be looked at and are important to be looked at.

  • Why is it important?

Tracking readmission rates provides information about the initial visit care and what our health care providers may need to do to keep patients healthy once they leave the hospital. 

 


Patient Safety/Harm (PSI-90 & HAC)

Patient Safety Indicators are specific quality indicators that look at occurrences of harm to patients. Collectively the measures are rolled up into a composite score known as PSI-90.  These indicators include measures such as accidental punctures and lacerations to post-operative hip fractures. The system also reviews other hospital acquired conditions (HACs) that are even broader than the PSI-90 measures, but are still conditions developed while receiving care in the hospital. 

  • Why is it important?

Any type of harm that is incurred while in the hospital is potentially avoidable. Given proper attention and education on these measures, hospitals strive to make these events never occur. 

 


Clinical Process of Care/Quality Measures

Clinical process of care or quality measures are specific measures set forth by regulatory bodies (such as the Center for Medicare/Medicaid Services or CMS) that look at how frequently certain events occur. For example, elective deliveries prior to 39 weeks gestation without medical necessity are generally discouraged. Measuring how frequently and why this event may occur helps to promote better care for our next patient. 

  • Why is it important?

Measuring how frequently and why this event may occur helps to promote better care for our next patient.

 


Patient Satisfaction

Patient Satisfaction measures are indicators that tell hospitals how patients perceive the care they received in the hospital.

  • Why is it important?

Patient Satisfaction measure help identify areas of strength and opportunity for hospitals to help provide better care to patients. It also helps tell hospitals and providers if the message they are trying to share with patients is being received appropriately. Care has the best outcome if patients feel supported in their care.