Quality Measures

Loyola University Health System (Loyola) is committed to safe, high quality health care. We believe it is our responsibility to publicly share the results of our care data in a scientifically responsible manner in order to help you make better decisions regarding your health care. We share information that the government, regulatory agencies and employers find helpful in understanding how hospitals are doing.

With so many sources for health-care information and measures, it's important to understand what to look for when reviewing such data.

• Most importantly, be sure the rankings are open to peer review and are based on scientifically valid measures, because many are not.
• Choose a source that is open about its methodology; find out exactly what they are measuring, the data sources and how old the data is.
  • Listings based on the reputation or popularity of hospitals and/or physicians are not using scientific measures of quality nor do they have scientific validity. Still others use self-reported data without any form of validation.
  • If it is Medicare-only data, keep in mind that this involves a specific age group, people over the age of 65. That information may not be applicable to younger adults and children. Does the ranking system use billing data only or is it supplemented with clinical data? In addition, results can be quite different unless they appropriately take into account how sick patients are and what other serious medical conditions are present – this is a very difficult and complex science.
• The source of the data needs to be a credible one. The firm that does the rankings should not require a hospital or physician to pay a fee in order to be ranked. Additionally, you should not have to pay for this type of information. It is available from credible, quality sources for free.

National Standards

Loyola has been putting quality measures on its Web site for three years, including measures that are not available publicly elsewhere. Among the organizations that conduct premier quality collection and reporting are:

• National Quality Forum (NQF), a public/private partnership charged with the task of creating a national quality measurement and reporting system
• University HealthSystem Consortium, an organization of major academic medical centers working to improve many aspects of health care
• The Joint Commission, an independent, not-for-profit organization that accredits and certifies health-care organizations and programs nationwide for quality and performance standards
• The U.S. Department of Health & Human Services' Centers for Medicare and Medicaid Services (CMS), a government agency that promotes quality care for its participants

Both the Joint Commission and CMS use NQF measures.

Loyola voluntarily participates in the CMS Hospital Quality Alliance, which is collecting and reporting data on the first few key measures of hospital care that are scientifically validated (heart attack care, heart failure care, pneumonia care).

Loyola compares very favorably in nearly all of the measurements. We are aware that our scores in a few areas are not optimal, and we have a team of experienced physicians, nurses and administrators actively working to address these issues. Loyola also is working to improve many other areas of care that are not yet part of the CMS alliance including: surgical infection rates, aspects of intensive care unit care and beta blockers to reduce heart attacks after surgery.

Quality Improvement Initiatives

Below we provide information about some important, common medical problems for which people often need medical care.

Quality of Care for Patients with a Myocardial Infarction (heart attack) (Chart)
There are a number of key steps in the care of patients with a heart attack including administration of medication, opening blocked arteries (angioplasty) and counseling patients about the important of quitting tobacco use. Loyola University Hospital provides these treatments in an excellent and consistent manner. Loyola has made particularly outstanding progress ensuring that patients who smoke get counseling and assistance to help them quit.

The mortality rate (chance of dying) of heart attack patients cared for at Loyola University Hospital is similar to national averages, but above expected values. A team of Loyola University Health System doctors, nurses, and pharmacists is working to reduce mortality following heart attack.

Quality of Care for Patients with Heart Failure (Chart)
Key care processes for patients with heart failure at Loyola University Hospital are consistently above national averages observed at both community hospitals and other academic medical centers.

Quality of Care for Patients with Pneumonia (Chart)
A team of Loyola University Health System doctors, nurses, pharmacists are working to improve the rapid administration of antibiotics to patients with pneumonia and to ensure that the receive vaccinations to prevent pneumonia and influenza.

Childbirth and Neonatal Care (Chart)
Childbirth can result in injury to the mother. The chance of vaginal tears during childbirth at Loyola is at expected rates as predicted by The Joint Commission. As a regional referral center for the care of critically ill infants, Loyola has followed neonatal outcomes for many years. The mortality rate (chance of dying) for infants less than 28 days cared for at Loyola University Hospital is below expected levels.

Preventing Surgical Infections (Chart)
Loyola University Health System tracks the use of antibiotics before surgery as an important step in the prevention of infections. Currently, a team of doctors, nurses, and pharmacists is working to ensure that 100% of patients who need antibiotics prior to surgery receive the correct antibiotic at the correct time.

Leapfrog Group for Patient Safety
The Leapfrog Group is a coalition of more than a 135 public and private organizations that encourages hospitals to improve the safety of their care. Leapfrog asks hospitals to voluntarily fill out a publicly available survey related to patient safety. Loyola University Health System has and will continue to complete this survey to share its safety practices.

The Leapfrog Group Standards
Some, but not all, scientific studies show a relationship between a hospital’s annual number of high-risk treatments and procedures and patient outcomes. Loyola University Hospital meets or exceeds the standards for the evidence-based hospital referral volume recommended by The Leapfrog Group, with the exception of coronary bypass surgery (CABG). The number of CABG surgeries has declined nationally as many patients are being treated less invasively with angioplasty and coronary stents. Despite CABG surgery volumes that are slightly less than Leapfrog standards, the mortality rate for CABG surgery at Loyola is consistently at or below rates predicted by the University HealthSystem Consortium and the Society for Thoracic Surgery.

Computers Prevent Potential Errors Caused by Handwriting
Loyola introduced a computer system in March 2002 to reduce medication errors related to hand-written orders for hospitalized patients. This has resulted in a 95 percent reduction in handwriting-related prescription errors. To further improve the quality and safety of care, a multi-million dollar, state-of-the-art electronic health record is now being implemented in all inpatient and outpatient settings throughout Loyola University Health System.

Additional Quality Improvement Initiatives

Quality in Diabetes Care (Chart)
In a quality initiative by University HealthSystem Consortium (UHC), Loyola ranked in the top 10-25 percent of peer hospitals for performance markers of quality care in diabetes, which are endorsed by the American Medical Association Physician Consortium for Performance Improvement.

Quality in Home Health Care
On Nov. 3, 2003, the federal Centers for Medicare and Medicaid Services, part of the U.S. Department of Health and Human Services, began providing the public with data on the quality of care home care agencies provide to their patients. Eleven measures have been selected and these reports are updated quarterly. Results may be viewed on the Medicare Home Care Compare web site.

Quality in Nursing Retention (Chart)
Loyola University Health System has made numerous efforts to improve the recruitment and retention of skilled nursing staff. Loyola improved its nursing retention from 87 percent in 2000, to better than 90 percent in 2003, well beyond the Chicago, regional, and national retention rates.

Dedication to Innovation at 10th Annual Quality and Safety Fair
A variety of innovative programs were showcased during the 10th annual Quality and Safety Fair on April 10 and 11, 2007. The fair featured 28 projects, each one sponsored by a team that presented a detailed display that explained the project's goals and its methods of implementation. Special presentations on patient safety were given by James P. Bagian, MD, PE, director, National Center for Patient Safety, Department of Veteran Affairs. Additional information about the fair may be obtained at Loyola's Center for Clinical Effectiveness Web site.