Clinical Excellence & Recognition: Quality Measures

The most common types of preventable harm in hospitals include infections, falls and medication errors. As part of our commitment to quality and patient safety Cayuga Health is becoming more transparent with our patients, community and employees. The Potential Preventable Events of Harm represent the number of events that could be considered a near miss (the potential error was caught before it reached a patient) or that did reach the patient but caused no harm to the patient. We proactively track and analyze each event to correct our processes and systems, to prevent it from happening again and causing harm to a patient.

Returning to the hospital for unplanned care disrupts patients’ lives, increases their risk of harmful events like healthcare-associated infections, and costs more money. Hospitals that give high quality care can keep patients from returning to the hospital and reduce their stay if they have to come back. The Overall Readmission Rate shows the percentage of patients who return to the hospital for an unplanned inpatient admission after leaving the hospital. By analyzing our 30 day readmissions we are able to identify improvement opportunities in our discharge planning process.

The Mortality Rate can provide information about important aspects of hospital care that affect patients outcomes – like prevention of and response to complications, emphasis on patient safety, and the timeliness of care. The Overall Mortality Rate shows the percentage of patients who died within 30 days of admission to a hospital (with some exclusions based on Center for Medicare and Medicaid criteria).

The HCAHPS Survey helps us to measure the patients’ perspective of hospital care they received.  The Care Transition Metric measures the % of patients who strongly agreed that:

• staff took their preferences into account when deciding what the patients healthcare needs would be when discharged
• the patient had a good understanding of what they were responsible for in managing their health
• the patient understood the purpose for taking each of their medications

We use this feedback to improve our processes related to the post discharge care plan for the patient.

Patient satisfaction measures are indicators that tell hospitals how patients perceive the care they received in the hospital. Patient feedback is key to identifying our areas of strength and opportunity. We believe that care has the best outcome if patients feel supported in their care.

There are a number of organizations that independently rate or rank healthcare providers. They include the Center for Medicare and Medicaid Services, The Joint Commission and the Department of Health.  The ratings for these organizations consider some of the same measures, but some can be different.  Use the links below to learn more about how each of these organizations determines ratings.