OSF St. Joseph Medical Center - Quality Improvements

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OSF St. Joseph Medical Center Quality Improvement

OSF St. Joseph Medical Center is dedicated to providing the highest quality and safest patient care in the region. Our Quality Improvement process involve staff from throughout the medical center including physicians, nurses, pharmacists, emergency and trauma service staff, as well as critical and intensive care departments.

Quality Improvement services include coordinating activities such as:

Incident reporting
Root cause analysis
Effects analysis
National patient safety goals
Education and awareness
Coordination of quality / performance improvement initiatives
Management of the Peer Review process
Facilitation of the Quality Reviews / Morbidity and Mortality Reviews
Quality indicator monitoring, benchmarking and reporting to numerous internal and external databases
Coordination of JC and other regulatory compliance
Clinical data analysis
Providing staff support and education on quality and patient safety issues.

Public Information About OSF St. Joseph Quality
One of the steps OSF St. Joseph has taken to provide the public with information about the quality of the care we provide is by participating in the Healthcare Quality Alliance, which is a collaborative effort between the Centers for Medicare & Medicaid Services, national hospital organizations, accrediting organizations, consumer advocates and others.

OSF St. Joseph was one of the first hospitals in the country to participate in this effort to improve care and make more information available to the public. Many hospitals have been providing information through this initiative since November 2003.

Below are the results of the most recent data we reported to the Alliance. It and information from other hospitals can be found at http://www.hospitalcompare.hhs.gov/hospital/home2.asp.

The state and national percentages displayed below are derived from the medical record data submitted by hospitals to the QIO Clinical Data Warehouse.

Quality Measures Data collected nationally from Hospitals submitting data to QIO Data Warehouse	Average for all reporting hospitals in the United States	Average for all reporting hospitals in the state of Illinois	OSF ST. JOSEPH MEDICAL CENTER BLOOMINGTON, IL
Heart Attack (AMI) Care
ACE Inhibitor for LVSD	85%	84%	19/24*
Aspirin at arrival	93%	93%	100%
Aspirin at discharge	90%	90%	100%
Beta blocker at arrival	88%	88%	94%
Heart Attack Patients Given Adult Smoking Cessation Advice/Counseling	91%	91%	100%
Beta blocker at discharge	91%	89%	94%
Heart Failure Care
ACE Inhibitor for LVSD	84%	85%	93%
Assessment of Left Ventricular Function	85%	90%	97%
Heart Failure Patients Given Adult Smoking Cessation Advice/Counseling	86%	86%	95%
Heart Failure Patients Given Discharge Instructions	66%	71%	94%
Pneumonia Care
Pneumonic Patients Assessed and Given Influenza Vaccination	75%	71%	79%
Initial Antibiotic Timing	93%	94%	97%
Oxygenation assessment	99%	99%	100%
Pneumococcal Vaccination	75%	71%	85%
Pneumonia Patients Having a Blood Culture Performed Prior to First Antibiotic Received in Hospital	90%	90%	78%
Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s)	86%	86%	91%
Pneumonia Patients Given Adult Smoking Cessation Advice	84%	84%	88%
Surgical Infection
Surgery Patients Who Received Preventative Antibiotic(s) One Hour Before Incision	82%	79%	95%
Surgery Patients Who Received Appropriate Preventative Antiobiotic(s)	90%	91%	97%
Surgery Patients Whose Preventative Antibiotic(s) are Stopped Within 24 hours After Surgery	78%	74%	80%

Survey of Patients' Hospital Experiences
How often did nurses communicate well with patients?
Nurses "always" communicated well	73%	73%	78%
Nurses "usually" communicated well	21%	21%	19%
Nurses "sometimes" or "never" communicated well	6%	6%	3%
How often did doctors communicate well with patients?
Doctors "always" communicated well	79%	80%	86%
Doctors "usually" communicated well	16%	15%	11%
Doctors "sometimes" or "never" communicated well	5%	5%	3%
How often did patients receive help quickly from hospital staff?
Patients "always" received help as soon as they wanted	60%	60%	65%
Patients "usually" received help as soon as they wanted	28%	27%	26%
Patients "sometimes" or "never" received help as soon as they wanted	12%	13%	9%
How often was patients' pain well controlled?
Pain was "always" well controlled	67%	68%	70%
Pain was "usually" well controlled	25%	24%	23%
Pain was "sometimes" or "never" well controlled	8%	8%	7%
How often did staff explain about medicines before giving them to patients?
Staff "always" explained	58%	57%	65%
Staff "usually" explained	18%	18%	18%
Staff "sometimes" or "never" explained	24%	25%	17%
How often were the patients' rooms and bathrooms kept clean?
Room was "always" clean	68%	69%	79%
Room was "usually" clean	21%	21%	17%
Room was "sometimes" or "never" clean	11%	10%	4%
How often was the area around patients' rooms kept quiet at night?
"Always" quiet at night	54%	53%	63%
"Usually" quiet at night	32%	32%	28%
"Sometimes" or "never" quiet at night	14%	15%	9%
Were patients given information about what to do during their recovery at home?
Yes, staff did give patients this information	79%	79%	80%
No, staff did not give patients this information	21%	21%	20%
How do patients rate the hospital overall?
Patients who gave a rating of "9" or "10" (high)	63%	62%	75%
Patients who gave a rating of "7" or "8" (medium)	26%	27%	20%
Patients who gave a rating of "6" or lower (low)	11%	11%	5%
Would patients recommend the hospital to friends and family?
YES, patients would definitely recommend the hospital	67%	66%	76%
YES, patients would probably recommend the hospital	27%	28%	22%
NO, patients would not recommend the hospital (they probably would not or definitely would not recommend it)	6%	6%	2%

Data Last Updated: March 21, 2008

* When less than 25 cases are reported, rather than presenting percentages, the number of cases meeting this criterion are in the numerator of the ratio and the denominator represents the total number of patients in the category.