UNION HOSPITAL HEALTH GROUP
Defining Quality: What To Look For in a Hospital

Keys to Hospital Quality

Who Defines and Measures Quality?

Accreditation Certifications

• Healthcare Facilities Accreditation Program (HFAP)
• Comprehensive Community Cancer Center, American College of Surgeons Commission on Cancer (UH Oncology Services since 1967)
• College of American Pathologists (Laboratory)
• American College of Radiology—Mammography (Clara Fairbanks Center for Women)
• Intersocietal Commission for the Accreditation of Vascular Laboratories (Cardiovascular Testing)
• Certificate of Recognition from American Diabetes Association meeting National Standard for Diabetic Self-Management Education (Diabetes Education Center)
• Commission for Accreditation of Rehabilitation Facilities (Medical Rehabilitation)
• American College of Radiology—Radiation Therapy (Hux Cancer Center)
• Indiana State Medical Society Continuing Medical Education Accreditation for Physicians—Six year accreditation with commendation, since 1992
  

Recognition

Eli Lilly Safety Consortium:
A consortium of health industry leaders led by Lilly evaluated Union Hospital’s patient safety program compared to other safety programs across the nation.
“The assessment determined that Union Hospital has been proactive in implementing standards to provide high-quality, safe patient care—far better than the national norm.” Mary Quinn, coordinator, wrote in its report.

Rankings

• Leapfrog: out of the 27 National Quality Forum-endorsed patient safety indicators, UH ranked 85th out of 896 facilities with a score of 994.25 out of a possible 1000 points; for the key practices (culture of safety, adequate nursing staff, medication reconciliation and effective and safe anticoagulation therapy) UH ranked 1 out of 1069 facilities with 505 points out of a possible 505 points.
• Anthem: scored 97% out of possible 100% on its 2005 Hospital Scorecard for Quality Indicators.

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Certifications/Recognition/Rankings from outside agencies

• UHA Leadership Award for Clinical Excellence in Treatment of Congestive Heart Failure
• Healthcare Facilities Accreditation Program (HFAP), last survey, May 2004
• Indiana State Department of Health rating, March 16, 2006, 0 Deficiencies
• Number of Board Certified Physicians by Specialty:
  • 262 board-certified physicians,
  • representing 34 specialties
  • 83% of medical staff certified
• Physician Medical Education Participation Rates: Average monthly participation rate 74%
• Patient Satisfaction Survey Results: Satisfaction score related to Doctor’s Care: 90.3%
  • Satisfaction score related to Nursing Care: 92.9%
  • Satisfaction score related to Housekeeping: 91.0%
  • Satisfaction score related to Food Service: 82.5%
  • Overall Patient Satisfaction Score: 88.9%
    (Source: Press Ganey Inpatient Satisfaction Survey, average 2nd Quarter 2005-2nd Quarter 2006, combined “good” and “very good” responses)
• Report quality data to:
  • LeapFrogGroup.org
  • HealthGrades.com
  • Other reporting entities: VHA
    • IHHA - Indiana Hospital & Health Association
    • Anthem
    • IHI 5 Million Lives Campaign
    • Healthcare Excel
    • VHA

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Quality improvement projects

• Medication errors:
  • Bar coding to be implemented 2007
  • high risk drug protocols in place for many years
  • 100,000 Lives Initiative fully implemented
  • Full commitment to 5 Million Lives initiatives
  • Indiana Patient Safety Organization Center leadership (Terri Hill of WCCH serves with the organization),
  • implementation of JCAHO Sentinel Event Alert recommendations,
  • Institute of Safe Medication protocols utilized,
  • Pyxis medication dispensing with barcode reconciliation
  • A+Plum Smart Pumps used with pre-programmed strength and flow control
• Fall Prevention:
  • toileting protocol
  • high risk assessments conducted
  • bed alarms on chairs/beds used for high risk patients
  • orange armbands used for ready identification of high risk patients
• Infection Rates:
  • Central Line-Associated Bloodstream Infection (CL-BSI) and Ventilator-Associated Pneumonia (VAP) bundles
  • new antibiotic-coated Foley catheters
  • CDC hand washing criteria
  • MRSA patient placement
  • Med Mined infection surveillance system (first in Indiana)
• Evidenced Based Practice Guidelines
  • AMI (Acute Myocardial Infarction)
  • CHF (Congestive Heart Failure)
  • CAP (Community Acquired Pneumonia)
  • SIP (Surgical Infection Prevention)
  • DVT (Deep Vein Thrombosis)
  • Sepsis
  • Glycemic Control
• 100,000 Lives Campaign: Implemented all six initiative
  • Deploy Rapid Response Teams
  • Deliver Reliable Evidence-Based Care for Acute Myocardial Infarction
  • Prevent Adverse Drug Events
  • Prevent Central Line Infections Prevent Surgical Site Infections
  • Prevent Ventilator-Associated Pneumonia

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