Quality and Safety

Loyola Medicine has long been committed to the quality of care and safety of its patients. We also believe in sharing quality information with the public and in participating in national quality improvement programs such as the federal Centers for Medicare and Medicaid Services Hospital Quality Alliance, the National Quality Forum, which is leading the development of a national quality measurement reporting system, and the University HealthSystem Consortium, an organization of major academic medical centers working to improve many aspects of healthcare.

Loyola prioritizes and coordinates performance improvement activities across the entire institution through its Center for Clinical Effectiveness (CCE). The CCE implements state-of-the-art quality and safety improvement tools, and communicates results of performance improvement work both within Loyola and to consumer, healthcare and academic audiences. Loyola dedicates $1 million of its annual budget to fund the work of the CCE.

The Center for Clinical Effectiveness (CCE) identifies ways to improve the quality and value of the healthcare services that Loyola provides. After areas for improvement are identified, the center coordinates and helps prioritize those performance improvement activities and efforts across Loyola. Once safety and quality improvement activities are completed, the CCE shares the performance improvement results within Loyola and externally to the community at large.

The CCE’s quality and safety improvement plans involve Loyola physicians, nurses, pharmacists, allied health professionals, administrators, managers, staff and contractors. Quality and safety improvement plans focus on improving key functions within Loyola. Such functions range from patient-focused areas such as rights and responsibilities and medication management to organizational functions of leadership and management of information.

Loyola is committed to safe, high quality healthcare. 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 healthcare. We share information that the government, regulatory agencies and employers find helpful in understanding how hospitals are doing.

With so many sources for healthcare 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—many are not.;
   
• Choose a source that is open about its methodology; find out exactly what is being measured, the source of data 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 you are reviewing 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 vary based on how they take into account the severity of illness and other serious medical conditions – this is a very difficult and complex science.
   
• The source of quality 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

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 healthcare
   
• The Joint Commission, an independent, not-for-profit organization that accredits and certifies healthcare 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. And we continuously look for ways to improve, with a team of experienced physicians, nurses and administrators actively working to identify opportunities to enhance our quality. 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.

In accordance with the Illinois Department of Public Health Hospital Report Card Act, the public has a right to access inpatient nurse staffing information. No personal information of the patient or staff will be provided. Requests for information regarding nurse staffing may be directed to the Nurse Staffing Office at 708-216-4321.

Ask questions.

• Choose a doctor you feel comfortable talking to.
• Write questions down and take them with you to your appointment.
• Take a relative or friend with you to help you ask questions and understand the answers.
• Make sure you understand the answers.

Keep a list of all the medicines you take.

• Bring your list of medications to all your doctor appointments.
• Include prescriptions, over-the-counter medicines and dietary supplements such as vitamins and herbs.
• Tell your doctor and pharmacist about any drug allergies you may have.
• Ask about side effects and what to avoid while taking the medication.
• Read the label and make sure you understand it.
• Ask your pharmacist if the medicine looks different than you expected.

Get test results.

• Ask when and how you will get results of tests or procedures.
• Don’t assume the results are fine if you do not get them when expected.
• Ask what your test results mean.

Talk to your doctor about specialty care.

• Ask your doctor to recommend specialists if needed.
• Ask who/what specialist is best to see based on your symptoms.

Understand what will happen if you need surgery.

• Ask who will manage your care while you are in the hospital.
• Tell the surgeon, anesthesiologist and nurses about allergies, reactions to anesthesia and medications you are taking.
• Make sure that you, your doctor and your surgeon all agree and are clear on exactly what will be done.
• Ask your surgeon how long your procedure will take and what you should expect to feel during recovery.
• Make sure you understand your instructions about follow-up care when you leave the hospital.

*Adapted from the AHRQ
Publication No. 03-M007, Five
Steps to Safer Health Care, Patient
Fact Sheet and AHRQ Publication
NO.00-PO38, 20 Tips to Help
Prevent Medical Errors, Patient Fact Sheet.