HQI Quality Dashboard - Community Hospital of the Monterey Peninsula

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The Hospital Quality Institute

Advancing Transparency in Hospital Quality Data Project

The California Hospital Association (CHA), in partnership with the Hospital Quality Institute (HQI), believe that hospitals need to be more transparent to the public and that transparency is critical in driving overall improvement in patient safety and quality. In February 2018, HQI launched their Advancing Transparency in Hospital Quality Data project and have invited every hospital in California to participate in the project by the end of 2018.  Like CHA and HQI, Community Hospital of the Monterey Peninsula takes patient safety and quality seriously as well and are proud to show our support of this project as an early adopter of this California-wide initiative. Our core patient outcome and process measures are reported below and follow the same methodology as other hospitals that are currently participating in this project. Although the numbers are important, we feel that it is equally important to share some of the work that is currently underway within the organization to ensure continued excellence in the future.

Outcome Measures:
How we compare* Community Hospital of the Monterey Peninsula California Level National Level
Lower is better

Central line-Associated Blood Stream Infection (CLABSI)*
A central venous catheter, or central line, is a long, thin flexible tube that is inserted directly into a large vein and is offer the best way to ensure that a patient is receiving the medicines, fluids or nutrients necessary for medical treatment over extended periods of time. Because the device provides direct access to the blood stream there is a risk that inserting the central line or improper maintenance of a central line may also directly introduce an infection into the blood stream. Blood stream infections are a know risk related to a central line, but our Infection Prevention Workgroup tries to mitigate this risk as much as possible. Following best practices with  the insertion and the ongoing maintenance of central lines is the best defense against infection.

Better 0.12 0.89 1.00
Colon Surgical Site Infection (Colon SSI)*
All surgeries carry a certain amount of risk and the decision to undergo surgery is always a trade-off between the benefits which will likely be realized from the surgery against the potential risks. An infection following a colon surgery is a very real risk and one that is receiving a lot of national attention. Through the work of the Infection Prevention Workgroup at Community Hospital of the Monterey Peninsula we evaluate the latest research and clinical practice guidelines in an effort to minimize this risk.  We take our patients' health seriously and our work does not end when they are discharged following a procedure, we also actively monitor all patients after discharge to ensure that they do not develop an infection in the weeks following a procedure even after they have gone home.
Better 0.53 0.92 1.00
Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate (NTSV)*
Community Hospital of the Monterey Peninsula is recognized as a "Baby Friendly" hospital which is due, in part, to the ongoing work of the Perinatal Work Group.  Representing a multidisciplinary membership including physicians, nurses and administrative staff, the work group focuses much of their attention towards reducing the hospital's C-section rate.  We do not do this work alone, by sharing our data through the California Maternal Quality Care Collaborative' s (CMQCC) Maternal Data Center and partnering with hospitals across the state in collaboratives we are able to ensure that we provide our new moms and babies with the best possible care in the Family Birth Center.
Better 20.7% 25% 25.7%

Sepsis Mortality*
Nation-wide, sepsis is a leading cause of deaths that occur in a hospital but Community Hospital of the Monterey Peninsula is working hard to change this statistic. The earlier we recognize and start treating sepsis, the more likely our patient will not become another statistic and will be able to make a full recovery.  Working with a multidisciplinary team of physicians, nurses and administrative staff our Sepsis Team ensures that staff on the front line have all the necessary tools and resources including ongoing education about sepsis as well as standard protocols that outline the optimal treatment of sepsis. With the launch of our new electronic health record, Epic, in August 2018, our ability to quickly identify the very early signs of sepsis will be greatly improved.  The Epic product includes a revolutionary early warning tool that can identify slight changes in a patients vital signs to ensure that we start treatment at the very earliest signs of an infection.

Better 22.3% 18.3% 25.0%

Venous thromboembolism (VTE)*
Venous thromboembolism (VTE) is a potentially deadly medical condition where a blood clot forms.  If the blood clot forms in a patient's leg, It is named “Deep Vein Thrombosis” or simply DVT.  A DVT can be dislodged and travels through the circulatory system and becomes stuck in the lungs (at which point, it becomes known as pulmonary embolism, PE). VTE is also a very real risk following surgery especially if a patient is less active and is in bed recovering.  The safest treatment for VTE is the prevention of DVTs. Community Hospital of the Monterey Peninsula's VTE team has focused their work on providing doctors standardized protocols which research has proven to be the best preventive treatment for DVTs.  Although the best treatment available, because this treatment is not always 100% effective, we also complete a clinical review of any patient who develops a DVT to ensure that we have provided the best clinical care possible for that patient.

Better 0.0% 2.0% 2.0%

This hospital has a Maternity Safety Program in place. A maternity safety program provides a coordinated approach and emergency response to risks associated with pregnancy and childbirth.

Yes

This hospital has a Sepsis Protocol in place. A sepsis protocol provides guidance for a coordinated approach to identification and treatment of an infection and inflammatory response which is present throughout the body.

Yes

This hospital has a Respiratory Monitoring program in place. Respiratory monitoring provides guidance for assessment of risk of respiratory depression, and includes continuous monitoring of breathing and functioning of the lungs and circulatory system when indicated.

Yes

*Measure definitions from the Hospital Quality Institute

CLABSI - Central line-Associated Blood Stream Infection: A serious infection that occurs when germs enter the bloodstream through a central line. A central line is a special intravenous catheter (IV) that allows access to a major vein close to the heart and 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 the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitation: In the calculation of the Standardized Infection Ratio (SIR), the CDC adjusts for differences between hospitals.  However, patient risk factors are not taken into account. These patient-specific variables (e.g., poor skin integrity, immunosuppression) can increase the risk of developing a central line infection.  Hence, the SIR for hospitals that care for more medically complex or immunosuppressed patients may not be adequately adjusted to account for those patient-specific risk factors.

Colon SSI - Colon Surgical Site Infection: An infection (usually bacteria) that occurs after a person has colorectal surgery that occurs at the body site where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, organs, or implanted material. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitation: Some, but not all patient-specific risk factors are included in the adjustment of the SIR for these types of infections.  However, not all relevant risk factors are included (e.g., trauma, emergency procedures).  Hence, the SIRs for hospitals performing 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.

NTSV - Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate: The percentage of cesarean (surgical) births among 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 in the hospital among primarily low risk, first-time mothers.  Limitation: NTSV rates do not take into account certain obstetric conditions, such as placenta previa, that may make Cesarean delivery the safer route for both mother and infant.

Sepsis Mortality: Percent of patients, with a severe infection, who die in the hospital. Most sepsis cases (over 90%) start outside the hospital. Lower percentage of death indicates better survival.  Limitation: Use of discharge/administrative data is limiting since such data has lower specificity for diagnoses than clinical data.  In addition, without risk adjustment for differences in patient-specific factors, comparing rates among hospitals is difficult.

VTE - Venous thromboembolism: The measure of patients who develop deep vein clots who had not received potentially preventive treatment. Limitation: Although not adjusted to account for patient-specific risk factors, this rate is helpful in distinguishing a hospital’s adherence to the best practice of administration of appropriate VTE prophylaxis to all appropriate patients.

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