Quality of Care FAQs
As the Chief Quality Officer, Dr. Cassagnol oversees the ongoing quality initiatives at University Hospital and answers these Frequently Asked Questions:
What information can I find here?
This website presents and explains data from the largest data sources used to create hospital "report cards": data from the Centers for Medicare & Medicaid Services (CMS) and data from the University HealthSystem Consortium (UHC). In addition, the nursing quality data is benchmarked through the National Database of Nursing Quality Indicators (NDNQI).
What does the data cover?
CMS measures data related to heart attacks, heart failure, surgical care, and pneumonia; while the UHC data compares our performance to other academic medical centers. The UHC data is based upon definitions prepared by the Agency for Healthcare Research and Quality (AHRQ) of numerous quality and patient safety measures.
University Hospital voluntarily supplies this information to the agencies. As this website grows, we will add more data sources.
How is this information collected?
The information collected by CMS is based on a review of patient charts. The CMS data presented here is exactly what you will find on the Department of Health and Human Services websites, and others. The UHC (AHRQ) data is based on patient diagnosis coding reports. NDNQI data is captured through a variety of methods including prevalence studies, operations, review of patient charts and actual occurrences.
Is this the same information found in other hospital "report cards" on the Internet?
Yes and no. Quality "report cards" are not identical: some are presented through government sites, others are commercially prepared, and some sites create reports for purchase. While most sites use the CMS and UHC data, others use different sources. Some quality report cards have been found to use older data — sometimes going back two years or more. The data reported on this site is committed to being the most recent.
Does every hospital put its quality data on the website?
Not every hospital puts its data on its own public website, but data is available through government Internet sites and commercially prepared reports. We want to put our data in a convenient place for health care consumers and others who may be interested. We aim to be open and transparent about our efforts to meet and exceed quality standards.
How should I use quality measures in selecting health care?
We believe quality measures are important. However, it's hard to draw conclusions from these alone. While outcome measures can give you valuable information ("outcomes" refer to what happens after treatment), your doctor's advice and your medical needs should be an important part of your health care decisions.
How else does University Hospital measure quality?
In addition to the many sources of publicly collected data, University Hospital also continually surveys patients on their experiences. This gives us immediate information on what we are doing well and what we need to address. Also, the doctors and nurses on our patient care floors, clinics, and offices have access to a wide range of reporting tools and quality information related to our patients on a secure intranet.
Every person who works at University Hospital has the responsibility to meet quality goals as part of his or her job description. The entire effort is represented in a comprehensive quality plan that provides the roadmap for all the hospital’s quality goals. Updates are shared on our staff intranet and in our Management Forum meetings.
How are the quality efforts structured?
There is a lot of attention paid to quality at University Hospital. A Council dedicated to Quality and Patient Safety has over twenty dedicated committees reporting through this structure. Each doctor, nursing unit, and department receives its own regular quality reports. There are many physicians who serve as quality officers at University Hospital and dedicated administrators who continually provide updates and oversight. However, while these are the formal roles, all hospital staff members are charged with contributing to ongoing quality improvement and are encouraged to bring forth initiatives that enhance the patient experience.
Hans P Cassagnol, MD
Chief Quality Officer