What do we mean by quality?
“Quality” in patient care means something very specific: it refers to clinical outcomes. So when we talk about improving quality at Jordan Valley Medical Center, what we’re really talking about are the things we do that make a medical difference in the lives of our patients. That can range from the new treatments, procedures, or medications that you can find at Jordan Valley Medical Center, to making continuous improvements in procedures and processes so we can always be as safe as possible.
“Service” in hospitals means something different from quality: it’s about all the little things we do as we work to create an experience for you that exceeds your healthcare expectations. 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.
In line with the HMMQP infrastructure, Jordan Valley 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 has 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.
Quality Watch
Agency for Healthcare Research and Quality (AHRQ)
The Agency for Healthcare Research and Quality (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 all their adult patients with certain medical conditions. This information will help you compare the quality of care hospitals provide. 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
The Institute for Healthcare Improvement (IHI) is a not-for-profit organization dedicated to the improvement of health care throughout the world. Jordan Valley 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 and Human Services (UDHHS)
Information about healthcare providers and services in the State of Utah.
www.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. Jordan Valley Medical Center has been accredited by DNV since July 2009. Prior to 2009, Jordan Valley Medical Center was accredited by The Joint Commission (TJC) from 1983 to July 2009.
www.dnvaccreditation.com
HealthInsight – Medicare’s Quality Improvement Organization (QIO)
HealthInsight serves as the Medicare Quality Improvement Organization (QIO) in Utah improving the quality, effectiveness, efficiency and economy of healthcare services provided to people insured by Medicare. Jordan Valley Medical Center actively participates in quality initiatives sponsored by HealthInsight.
www.healthinsight.org
Core Measure - Quality Measures
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. Jordan Valley Medical Center has partnered with local EMS to provide advanced technology to diagnose heart attack victims in the field. This 12-Lead system allows EMS to communicate electrocardiogram (EKG) results to Emergency Department physicians through a remote connection. The EKG machine in the ambulance is linked to a cell phone via Bluetooth and the patient’s results are communicated to the hospital via wireless connection.
The transmission allows physicians to diagnose heart attack victims before seeing them. Even though a Paramedic may believe a patient has suffered a heart attack, treatment cannot begin until they have been diagnosed by a doctor. Because the 12-Lead system allows Emergency Room doctors to monitor a patient’s vital signs before they arrive, necessary preparations, treatments and medicines can be arranged for the victim prior to arrival. Without this technology, patients can sometimes wait 20 extra minutes upon arriving at the Emergency Room. Jordan Valley Medical Center’s average AMI door-to-balloon times average 60 minutes (30 minutes faster than the national benchmark).
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 data below represents an overall average of the comprehensive ratings/scores.
The bar graph above represents Jordan Valley 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 Jordan Valley Medical Center’s performance, in comparison to the National and State average. Jordan Valley 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 measures include: documentation by the physician that evaluates the patient’s ability to pump blood through the heart, smoking cessation education, and medications prescribed at time of discharge to help the heart pump blood throughout the body. The data below represents an overall average of the comprehensive ratings/scores.
The bar graph above represents Jordan Valley 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 Jordan Valley Medical Center’s performance, in comparison to the National and State average. Jordan Valley Medical Center’s performance is above the National and State average (the higher percentage the better).
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 data below represents an overall average of the comprehensive ratings/scores.
The bar graph above represents Jordan Valley 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 Jordan Valley Medical Center’s performance, in comparison to the National and State average. Jordan Valley 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 Jordan Valley 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 Jordan Valley Medical Center’s performance, in comparison to the National and State average. Jordan Valley Medical Center’s performance is above the National and State average (the higher percentage the better).
Results - Quality Measures
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. The National data used for this posting is one quarter behind Jordan Valley Medical Center’s data posted above.
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. The State data used for this posting is one quarter behind Jordan Valley Medical Center’s data posted above.
Footnote 3: The “Jordan Valley” 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.