Measuring Quality

How do we measure quality? Throughout the hospital we measure it in numerous ways, and we use the measurements we gather to make needed improvements system wide.

We continuously evaluate the quality of care provided to patients by measuring:

• timeliness of care
• adherence to evidence-based guidelines
• patient outcomes
• observation

Some of our measures, called Core Measures, are provided by and reported to the Centers for Medicaid & Medicare Services (CMS). Others are required by the certifying and accrediting organizations to which we subscribe, including The Joint Commission (TJC), the American College of Radiology (ACR), the American Heart Association's "Get With the Guidelines" Program and the South Carolina Safe Care Program.

Following are several of the key patient-care services we monitor and the ways in which we measure the quality and safety of the care we provide.

Heart and Stroke Care

Because “time is muscle" and “time is brain,” we take steps to ensure that our heart and stroke patients receive appropriate care as soon as they pass through our doors.

For these patients we measure

• "door-to-balloon" time, the time it takes for a heart attack patient to get from the door to our catheterization lab for a life-saving intervention
• whether aspirin is given on arrival, a national standard of care that has been demonstrated to improve outcomes
• the time it takes a suspected stroke patient to get a CT scan

Orthopedic Care

We pride ourselves on providing the highest level of orthopedic care. Our Joint Replacement Center (JRC), which recently received The Joint Commission's disease-specific certification for total hip and total knee replacement, has also been recognized by Blue Cross Blue Shield as a Center of Distinction for quality outcomes in joint replacement.

We and other certifying bodies measure the quality of orthopedic care in a number of ways, including:

• length of stay, which indicates how quickly a patient is able to return home and begin post-surgical rehabilitation
• surgical site infections, which measure the success of our infection prevention methods
• physical therapy goals, which determine whether a patient is discharged to home or to a nursing home for further recovery

Maternity Care

Since delivering our first baby on May 1, 1944, we’ve continued our tradition of providing excellent maternity care to mothers and infants for more than 70 years. We take pride in caring for our newborns, and our quality is measured by

• infections, which we work diligently to prevent through the appropriate use of antibiotics, surgical-site preparation and a number of other protocols
• deliveries, which follow national guidelines approved by the American College of Surgeons, the American College of Obstetricians and Gynecologists and the Institute of Medicine. These guidelines specify how deliveries are monitored, when a cesarean section is recommended for first-time mothers, and how we manage infants in our Level II nursery.
• exclusive breastfeeding, which is a recognized predictor of the health of an infant as he or she begins to grow. To assist mothers with successful breastfeeding, we employ certified breastfeeding counselors and all birthing center nursing staff are trained in breastfeeding consultation.

Pneumonia and Influenza Vaccinations

For the safety of patients and caregivers, all hospitals are required to provide pneumonia and flu vaccinations to inpatients of a certain age during their hospital stay. Our current rate of pneumonia and flu vaccination is 96 percent, compared with a national average of 93 percent.

Radiology Services

We base the use of radiology and imaging services on claims reports to ensure that we are using the services appropriately and only when medically necessary. The majority of our scores in this area are below state and national averages, which indicates our adherence to guidelines.

The two areas in which we are working to improve those scores are:

• combined sinus/head CTs
• the use of cardiac screening for risk assessment for non-cardiac -risk patients

Outpatient Services

With more than 185,000 outpatient visits to our hospital each year—and another 50,000 to our Emergency Department (ED)—we take the care of our patients very seriously. Measures of our ED quality of care include:

• management of pain for long-bone fractures (average of 43 minutes compared with the national average of 54 minutes)
• median time from patient arrival to diagnostic evaluation by a physician (average of 17 minutes compared with national average of 27 minutes)
• median time from patient arrival at to discharge from ED (average of 149 minutes is on par with the national average)