Clinical Excellence & Recognition: Quality Measures

Centralus Health is comprised of two established local health systems, united as one collaborative network. Centralus Health, an affiliation of Arnot Health and Cayuga Health, focused on our region’s changing needs and patient wellbeing.  

Centralus Health’s Mission is to deliver high-quality care; empower our teams to succeed and improve the wellbeing of the communities we serve.

Centralus Health’s Vision is to grow a best-in-class integrated delivery network.

The Quality Assurance and Performance Improvement (QAPI) program is systematic, comprehensive, data‑driven, and proactive, grounded in the principles of High Reliability with a strong commitment to zero harm. Essential components of our quality plan include Quality Improvement, Patient Safety, and Patient Experience. 

QAPI goals are routinely monitored to assess the effectiveness of improvement activities, impact on outcomes, committee structures, resource adequacy, and alignment with mission and strategic goals. Through this integrated approach, the organization consistently seeks to strengthen systems, anticipate risks, minimize preventable harm, and promote a culture of safety and continuous improvement.

Performance Improvement priorities are identified and established annually by leadership  in collaboration with the Board. When establishing priorities and strategic goals, the following criteria are considered to ensure alignment with our Mission Vision, & Values and essential components – Quality Improvement, Patient Safety Risk Management, and Employee Satisfaction & Patient Experience:

• Mission, Vision, and Values

• Quality Improvement
  • Core Measures – CMS & TJC (Standardized Evidence-Based Best Practice)
  • CMS Hospital Care Compare, CMS 5 Star Rating (Hospital, Nursing Home, Home Health)
  • TJC National Performance Goals – Hospital& Critical Access Hospital (CAH)
  • Clinical record and utilization review findings
  • Competency and training needs
  • Community Health Assessment & Improvement Planning(CHA/CHIP) opportunities
  • Value-Based Purchasing Program Quality Improvement Collaborative Projects & opportunities
  • Leapfrog Hospital Ratings(Survey Results) & Hospital Safety Grade opportunities
  • Other Branding/ Certification/ Recognition Agencies and Programs (e.g., Blue Distinction, Age Friendliness, TJC Accreditation, NYSDOH CLEP Accreditation, CARF Accreditation, NYS Nursing Home Accreditation, etc.)

• Patient Safety/Risk Management
  • Patient Safety Indicators(PSI)
  • National Quality Forum(NQF) – Key Initiatives – Focus on Harm
  • Serious Reportable Events(SRE) & Incident Report Trends

• Employee Satisfaction & Patient Experience
  • Perception of Care Survey feedback
  • Culture of Safety Survey feedback
  • Employee Engagement Survey feedback
  • Physician and Nursing Survey feedback

The organization is committed to a culture of Zero Harm, where every resident, patient, family member, and employee is protected from preventable injury. This commitment drives our approach to quality, safety, and high reliability, ensuring that all team members actively identify risks, speak up for safety, follow evidence- based practices, and participate in continuous improvement. Zero Harm is not a slogan—it is an expectation that guides decision‑making, resource allocation, process redesign, and daily behaviors so that we consistently deliver safe, reliable, equitable care. Through strong leadership, transparent reporting, data‑driven learning, and systemwide accountability, we strive to eliminate preventable harm and create an environment where excellence in safety is the standard for every patient, every time.