How do we monitor quality?

Monitoring our performance is an integral part of the responsibilities of the quality director, chief executive officer, medical staff, and local governing boards.  On a monthly basis, we track more than 200 clinical indicators and equally as many in other aspects of the business operations. 

We collaborate with the Centers for Medicare and Medicaid Services (CMS) Quality Initiatives as well as with The Joint Commission to provide many of these indicators to you already. 

We currently publicly report information on the Acute Myocardial Infarction (AMI, also know as heart attack), Congestive Heart Failure (CHF), and Community Acquired Pneumonia (CAP).  Beginning with April 1, 2007 discharges, we will also be publicly reporting information on Surgical Care Improvement Project (SCIP) measures addressing the prevention of post-operative surgical infections.

In addition, CMS has partnered with the Agency for Healthcare Research and Quality (AHRQ), another agency in the Department of Health and Human Services, to develop HCAHPS-the Hospital Consumer Assessment of Healthcare Providers and Systems Survey. We have voluntarily chosen to participate.