Quality Care
Measuring Quality
One of the ways we constantly improve is by measuring ourselves, so we can find out how we’re doing compared to other, similar institutions. In addition, we are advocates and participate in initiatives to improve the quality and safety of patient care, in collaboration with leading quality organizations such as the Institute for Healthcare Improvement (IHI), the Agency for Healthcare Research and Quality (AHRQ), and National Quality Forum (NQF).
What do we mean by quality?
“Quality” in patient care means something very specific: it refers to clinical outcomes. That can range from the new treatments, procedures, or medications that you can find at Davis Hospital and Medical Center, to making continuous improvements in procedures and processes so we can always be as safe as possible.
What do we mean by service?
“Service” in hospitals means something different from quality: it’s about all the little things we do to make your experience with us a good one. That can range from how we communicate with you, to how quickly we respond to your concerns, to the kinds of amenities you find in your room.
What are we doing to improve?
In line with the HMMQP infrastructure, Davis Hospital and Medical Center has a robust safety event reporting system, and our leadership encourages all members of the hospital’s staff to report adverse events and close calls. All hospital staff and employees have access to computer terminals and are encouraged to report events so that investigations can be conducted and improvements can be made. We want our employees to feel comfortable reporting events, and understand that reporting and learning from our events leads to a culture supportive of patient safety. All events that fall in the category of serious adverse events are extensively reviewed and analyzed as part of our ongoing and comprehensive safety reporting system.
What are we doing to be transparent?
Davis Hospital and Medical Center’s commitment to “transparency” includes providing the most current quality data available, and that is what this Quality Dashboard Report will show you. On an ongoing basis, the Dashboard will be updated as new data becomes available.
The Quality Dashboard Report shows how Davis Hospital and Medical Center has been doing at providing the right care for some common conditions. Information about surgery, certain types of infections, and how patients view their experiences at Davis Hospital and Medical Center is also included.
Do you want to tell us something?
We can’t make improvements alone, we need your feedback, whether that is through patient surveys, letters, emails, or telephone calls. We encourage you to be involved in resolving issues regarding your own care, treatment and services. To express concerns, complaints and/or a grievance you can contact us via mail, e-mail, or telephone.
Davis Hospital and Medical Center
1600 W Antelope Dr.
Layton, UT 84041
Switchboard: (801) 807-1000
Email: [email protected]
Quality Watch
The following contains links to organizations that monitor (watch) quality in healthcare nationally and in the State of Utah.
Agency for Healthcare Research and Quality (AHRQ)
AHRQ Quality Indicators (QIs) are measures of health care quality that make use of readily available hospital inpatient administrative data.
www.qualityindicators.ahrq.gov
Hospital Compare Website
This tool provides you with information on how well the hospitals in Utah (or any where in the United States) care for their adult patients with certain medical conditions. Hospital Compare was created through the efforts of the Centers for Medicare and Medicaid Services (CMS) and organizations that represent hospitals, doctors, employers, accrediting organizations, other Federal agencies and the public.
www.hospitalcompare.hhs.gov
IHI – Institute for Healthcare Improvement
IHI is a not-for-profit organization dedicated to the improvement of health care throughout the world. Davis Hospital and Medical Center actively participates in many IHI initiatives.
www.ihi.org/IHI
NQF – National Quality Forum
The National Quality Forum is a private, not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting.
www.qualityforum.org
Utah Department of Health (UDOH)
Information about healthcare providers and services in the State of Utah.
http://health.utah.gov
Det Norske Veritas (DNV)
DNV Healthcare offers hospital accreditation approved by the Centers for Medicare and Medicaid Services (CMS). Annual deemed status surveys are an essential component of hospital accreditation through DNV.avis Hospital and Medical Center has been accredited by DNV since July 2009.
www.dnvaccreditation.com
HealthInsight – Medicare’s Quality Improvement Organization (QIO)
HealthInsight serves as the Medicare Quality Improvement Organization (QIO) in Utah and Nevada improving the quality, effectiveness, efficiency and economy of healthcare services provided to people insured by Medicare. Davis Hospital and Medical Center actively participates in quality initiatives sponsored by HealthInsight.
www.healthinsight.org
Quality Measures - Core Measure Results
Core Measure Results
A heart attack (also called AMI or acute myocardial infarction) happens when the arteries leading to the heart become blocked and the blood supply is slowed or stopped. These measures show some of the process of care provided, if appropriate for most adults who have had a heart attack. These measure include: Aspirin on arrival and at discharge, smoking cessation education, timeliness of medications that help the heart pump blood throughout the body.
The bar graph above represents Davis Hospital and Medical Center’s performance in all categories of publicly reported Acute Myocardial Infarction data. The first bar graph represents the average performance for all reporting hospitals in the United States, known as the “National Average”. The middle (second) bar graph represents the average performance for all reporting hospitals in the State of Utah, known as the “Utah Average”. The last bar graph represents Davis Hospital and Medical Center’s performance, in comparison to the National and State average. Davis Hospital and Medical Center’s performance is above the National and State average (the higher percentage the better).
Heart Failure is a weakening of the heart’s pumping power. With heart failure, your body doesn’t get enough oxygen and nutrients to meet its needs. These measures show some of the process of care provided for most adults with heart failure. These measure include: documentation by the physician that evaluates the patient’s ability to pump blood through the heart, smoking cessation education, medications prescribed at time of discharge to help the heart pump blood throughout the body.
The bar graph above represents Davis Hospital and Medical Center’s performance in all categories of publicly reported Heart Failure data. The first bar graph represents the average performance for all reporting hospitals in the United States, known as the “National Average”. The middle (second) bar graph represents the average performance for all reporting hospitals in the State of Utah, known as the “Utah Average”. The last bar graph represents Davis Hospital and Medical Center’s performance, in comparison to the National and State average.
Pneumonia is a serious lung infection that causes difficulty breathing, fever, cough and fatigue. These measures show some of the recommended treatments for pneumonia. These measure include: obtaining blood cultures drawn in the Emergency Department prior to the first antibiotic being given to the patient, ensuring the first antibiotic is given within 6 hours of arrival to the hospital, appropriate antibiotic selection, smoking cessation education, and assessing the need for vaccinations related to pneumococcal and influenza.
The bar graph above represents Davis Hospital and Medical Center’s performance in all categories of publicly reported Pneumonia data. The first bar graph represents the average performance for all reporting hospitals in the United States, known as the “National Average”. The middle (second) bar graph represents the average performance for all reporting hospitals in the State of Utah, known as the “Utah Average”. The last bar graph represents Davis Hospital and Medical Center’s performance, in comparison to the National and State average. Davis Hospital and Medical Center’s performance is above the National and State average (the higher percentage the better).
Hospitals can reduce the risk of infection after surgery by making sure they provide care that’s known to get the best results for most patients. Here are some examples:
- Giving the recommended antibiotics at the right time before surgery
- Stopping the antibiotics within the right timeframe after surgery
- Maintaining the patient’s temperature and blood glucose (sugar) at normal levels
- Removing catheters that are used to drain the bladder in a timely manner after surgery.
Hospitals can also reduce the risk of cardiac problems associated with surgery by:
- Making sure that certain prescription drugs are continued in the time before, during, and just after the surgery. This includes drugs used to control heart rhythms and blood pressure.
- Giving drugs that prevent blood clots and using other methods such as special stockings that increase circulation in the legs.
The bar graph above represents Davis Hospital and Medical Center’s performance in all categories of publicly reported Surgical Infection Prevention data. The first bar graph represents the average performance for all reporting hospitals in the United States, known as the “National Average”. The middle (second) bar graph represents the average performance for all reporting hospitals in the State of Utah, known as the “Utah Average”. The last bar graph represents Davis Hospital and Medical Center’s performance, in comparison to the National and State average. Davis Hospital and Medical Center’s performance is performing above the National average and the State average (the higher percentage the better).
Quality Measures - Outcome of Care Measures Results
One way to tell whether a hospital is doing a good job is to find out whether patients admitted to the hospital have death (mortality) rates that are lower (better) than the U.S. National Rate, about the same as the U.S. National Rate, or higher (worse) than the U.S. National Rate, given how sick they were when they were admitted to the hospital. “30-Day Mortality” is when patients die within 30 days of their admission to a hospital. Below, the death rates for each hospital are compared to the U.S. National Rate. The rates take into account how sick patients were before they were admitted to the hospital.
“30-Day Readmission” is when patients who have had a recent hospital stay need to go back into a hospital again within 30 days of their discharge. Below, the rates of readmission for each hospital are compared to the U.S. National Rate. The rates take into account how sick patients were before they were admitted to the hospital.
Source Data: www.hospitalcompare.hhs.gov
Footnote 1: The “National Average” is an aggregate percentage calculated by averaging the percent compliance for each indicator, in each Core Measure category, as posted on the source data page.
Footnote 2: The “Utah Average” is an aggregate percentage calculated by averaging the percent compliance for each indicator, in each Core Measure category, as posted on the source data page.
Footnote 3: The “Davis Hospital” average is an aggregate percentage calculated using the numerator and denominator for each indicator, in each Core Measure category, as posted on the source data page.
Footnote 4: The Surgical Care Improvement Project (SCIP) aggregate percentage for the National, State and Davis Hospital averages does not include SCIP-Inf-4 Cardiac Surgery Patients, since Davis Hospital does not perform open heart procedures.
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