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Quality Transparency Dashboards

2017 Quality Transparency Dashboard

We strive to deliver the highest quality care in a safe environment, and ensure that our patients will leave here completely satisfied with their experience. We’ve partnered with the Hospital Quality Institute (HQI), the Patient Safety Movement Foundation (PSMF) and the California Hospital Association (CHA) to increase transparency in our patient safety data and empower you to make the best decisions about your healthcare. As a patient, you can be confident in our commitment to improving safety and quality of care to everyone we serve.

The Quality Transparency Dashboard is designed to provide transparency into five key quality of care metrics measured across all California hospitals. Lower numbers are indicative of better performance. Below you will see our measurements compared to both California and National levels.

Data for this dashboard is compiled from the following state and national public databases:

Dashboards

Central Line-Associated Bloodstream Infection (CLABSI)

Measure Period: 01/01/2017 - 12/31/2017

Central line-associated bloodstream Infection (CLABSI): This is a serious infection that occurs when germs enter the bloodstream through a central line (a special intravenous catheter that allows access to a major vein close to the heart, and which can stay in place for weeks or months). The value shown above is a standardized infection ratio (SIR), which is the ratio of observed-to-expected infections during a certain period of time. SIRs below 1.00 indicate that the observed number of infections during the measured period was lower than would be expected under normal conditions, while values above 1.00 indicate that the observed number of infections was higher than expected.

Limitation: When calculating the SIR, the Centers for Disease Control and Prevention (CDC) adjust for differences between hospitals, but patient risk factors aren’t taken into account. These patient-specific variables (such as poor skin integrity or a suppressed immune system) can increase the risk of developing a central line infection.

Colorectal Surgical-Site Infection (SSI)

Measure Period: 01/01/2017 - 12/31/2017

Colorectal surgical-site infection (SSI): An infection (usually bacterial) that occurs after a person has had colorectal surgery, which occurs at the site on the body where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, the organs, or implanted material. The value shown above is a standardized infection ratio (SIR), which is the ratio of observed-to-expected infections during a certain period of time. SIRs below 1.00 indicate that the observed number of infections during the measured period was lower than would be expected under normal conditions, while values above 1.00 indicate that the observed number of infections was higher than expected.

Limitation: Some patient-specific risk factors are included in the adjustment of the SIR for these types of infections, but not all (such as trauma or emergency procedures). As a result, the SIR for hospitals that perform more complex procedures, or with larger volumes of trauma or emergency procedures, may not be adequately adjusted to account for those patient-specific risk factors.

Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate

Measure Period: 01/01/2017 - 12/31/2017

Nulliparous, Term, Singleton, Vertex (NTSV) cesarean birth rate: This is the percentage of cesarean (surgical) births that occur among primarily low-risk, first-time mothers, who are at least 37 weeks pregnant with one baby in a head-down position (not breech or transverse). Lower values indicate that fewer cesareans were performed among this group of mothers.

Limitation: NTSV rates don’t take into account certain obstetric conditions, such as placenta previa, that may make a cesarean delivery the safer route for both mother and infant.

Sepsis Mortality

Measure Period: 01/01/2017 - 12/31/2017

Sepsis mortality: This is the percentage of patients with a severe infection who die in the hospital. Most cases of sepsis (over 90%) start outside the hospital. A lower percentage indicates better survival rates.

Limitation: The use of discharge/administrative data is less specific than clinical data in providing a diagnosis. In addition, without adjusting for differences in patient-specific risk factors, comparing rates among hospitals is difficult.

Venous Thromboembolism

Measure Period: 01/01/2017 - 12/31/2017

Venous thromboembolism (VTE): The measure of patients who developed deep-vein blood clots and who hadn’t received potentially preventive treatment.

Limitation: Although this rate isn’t adjusted to account for patient-specific risk factors, it’s helpful in distinguishing a hospital’s adherence to the best practice of administering appropriate VTE prophylaxis (preventive measures) to all appropriate patients.

1 The number of cases/patients is too few to report.

Program Status

Maternity Safety Program

This hospital has a maternity safety program in place. The program provides a coordinated approach and emergency response to risks associated with pregnancy and childbirth, such as severe hypertension, excessive bleeding, and blood clots.

Sepsis Protocol

This hospital has a sepsis protocol in place. The protocol provides guidance for a coordinated approach to identification and treatment of a serious infection that can result in damage to multiple organ systems, causing them to fail.

Respiratory Monitoring Program

This hospital has the components in place for a respiratory monitoring program. The full program will be in place by April 1, 2019. Once fully implemented the program will provide guidance for assessment of risk of respiratory depression, and include continuous monitoring of breathing, and functioning of the lungs and circulatory system, when indicated.

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