 UNION HOSPITAL
Defining Quality: What To Look For in a Hospital
Quality is defined in various ways. In health care, there are many important factors, governing bodies, measurements, awards and key areas to consider. For instance, the experience that a hospital's physicians possess, a link to a teaching facility, ongoing research, national recognition and awards received, use of cutting-edge technologies and a dedication to improving patient safety and quality of life are all significant factors to consider. It is the total picture that helps define a hospital system's overall commitment to quality.
Keys to Hospital Quality
Who Defines and Measures Quality?
Accreditation/ Certifications
- Healthcare Facilities Accreditation Program (HFAP) for UH and WCCH - WCCH due in 2009 and UH in 2010
- Commission for Accreditation of Rehabilitaiton Facilities (CARF) for medical rehab (3 year cycle - due 2011)
- Indiana State Medical Society Continuing Medication Education Accreditation for Physicians (6 yar cycle due to accreditation with commendation otherwise would be 3 year cycle - due 2008)
- College of American Pathologists for Laboratory (2 year cycle - due 2008)
 National Assocation for the Education of Young Children for Child Developement Center (annually validated by written report with survey due 2010)- American College of Radiology - Radiation Therapy for Hux Cancer Center
- American College of Radiology - Mammography for Clara Fairbanks Center for Woment (3 year cycle - due in 2009)
- Certificate of Recognition from the American Diabetes Association for meeting National Standard for Diabetic Self-Management Education - Diabetes Education Center (3 year cycle - due 2009)
- Intersocietal Commission for the Accreditation of Vascular Laboratories for Cardiovascular Testing (3year cycle - due in 2011)
- Mammography Quality Standards Act for Clara Fairbanks Center for Women (1 year cycle - due in 2008)
- American College of Surgeons Commission on Cancer - Comprehensive Community Cancer Center - UH Oncology (3 year cycle - due in 2010)
Rankings
- Leapfrog: out of the 27 National Quality Forum-endorsed patient safety indicators, UH had a score of 664.40 out of a possible 707 points.
- Anthem: scored 93% out of possible 100% on its 2007 Hospital Scorecard for Quality Indicators.
Union Hospital is accredited through HFAP
It is one of only two voluntary accreditation programs in the United States authorized by the Center for Medicare & Medicaid Services (CMA), formerly HCFA, to survey hospitals under Medicaree. In addition, the program is a cost effective, user friendly means to validate the quality of care provided by a facility.
The Joint Commission (TJC)
TJC provides accreditation to hospitals that maintain a certain baseline of quality standards. TJC's mission is to improve the safety and quality of care through certified accreditation and relatedd services that support improvement in health care organizations, especially hospitals. The Joint Commission is a nonprofit organization that evaluates and accredits 15,000 health care organizations and programs in the United States. While Union Hospital does not use TJC accrediting body, Union Hospital implements TJC guidelines recommended in its Sentinel Event Alerts.
HealthGrades
HealthGrades Inc. is a for-profit health care ratings, data and advisory company. HealthGrades provides customers with solutions to measure and assess health care quality by market area. General hospital information is provided to consumers for free; however, in-depth reports are available for order.
The Leapfrog Group
The Leapfrog Group is an initiative focused on driving breakthrough improvements in quality, especially safety in health care. The initial focus of the Leapfrog Group is to improve patient safety reducing preventable medical mistakes.
National Quality Forum (NQF)
A private, nonprofit membership organization, the National Quality Forum was created to improve care through establishment of national standards for measurement and reporting on safe, timely, efficient, equitable, patient-centered care. The NQF has members from all aspects of health care, national, state and regional groups that represent cunsumers and the general health care system plans, hospitals and supporting industries and organiations. The NQF board of directors includes members from two key federal agencies, CMS (Medicare) and the Agency for Health Care Research and Quality, votes to endorse quality measures for national use and develops a research agenda for quality improvement.
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Recognition/Rankings from outside agencies
- UHA Leadership Award for Clinical Excellence in Treatment of Congestive Heart Failure
- Number of Board Certified Physicians by Specialty:
- 262 board-certified physicians,
- representing 34 specialties
- 83% of medical staff certified
- Physician Medical Education Participation Rates: Average monthly participation rate 74%
- Patient Satisfaction Survey Results: Satisfaction score related to Doctor’s Care: 90.3%
- Satisfaction score related to Nursing Care: 92.9%
- Satisfaction score related to Housekeeping: 91.0%
- Satisfaction score related to Food Service: 82.5%
- Overall Patient Satisfaction Score: 88.9%
(Source: Press Ganey Inpatient Satisfaction Survey, average 2nd Quarter 2005-2nd Quarter 2006, combined “good” and “very good” responses)
- Report quality data to:
- LeapFrogGroup.org
- Other reporting entities:
- IHHA - Indiana Hospital & Health Association
- Anthem
- IHI 5 Million Lives Campaign
- Healthcare Excel
- VHA
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Quality improvement projects
- Medication errors:
- Bedside bar coding for medication administration implemented
- high risk drug protocols in place for many years
- 100,000 Lives Initiative fully implemented
- 5 Million Lives initiatives implemented
- Indiana Patient Safety Organization Center leadership (Terri Hill of WCCH serves with the organization),
- implementation of JCAHO Sentinel Event Alert recommendations,
- Institute of Safe Medication protocols utilized,
- Pyxis medication dispensing with barcode reconciliation
- A+Plum Smart Pumps used with pre-programmed strength and flow control
- Fall Prevention:
- toileting protocol
- high risk assessments conducted
- bed alarms on chairs/beds used for high risk patients
- orange armbands used for ready identification of high risk patients
- Infection Rates:
- Central Line-Associated Bloodstream Infection (CL-BSI) and Ventilator-Associated Pneumonia (VAP) bundles
- Anti-infective silver alloy coated Foley catheters with antimicrobial tubing implemented
- CDC hand washing criteria
- MRSA patient placement
- MRSA bundle implemented
- Med Mined infection surveillance system (first in Indiana)
- Catheter Associated Urinary Tract Infection Prevention Bundle implemented
- Evidenced Based Practice Guidelines
- AMI (Acute Myocardial Infarction)
- CHF (Congestive Heart Failure)
- CAP (Community Acquired Pneumonia)
- SIP (Surgical Infection Prevention)
- DVT (Deep Vein Thrombosis)
- Sepsis
- Glycemic Control
- 100,000 Lives Campaign: Implemented all six initiative
- Deploy Rapid Response Teams
- Deliver Reliable Evidence-Based Care for Acute Myocardial Infarction
- Prevent Adverse Drug Events
- Prevent Central Line Infections Prevent Surgical Site Infections
- Prevent Ventilator-Associated Pneumonia
- 5 Million LIves Campaign
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