At Rush, our mission is to provide the best possible care for our patients. We measure many aspects of our care processes and our clinical outcomes to ensure that our patients get the very best care available. Learn more about our quality measures below.
Rush's quality measurements
Core performance measures
Core measures show how consistently hospitals give recommended treatments for certain common conditions. The most commonly used and compared nationally are the core measures established by the Joint Commission based on data from the Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare and Medicaid.
The measures are based on uniform standards for health care processesand the outcomes of those processesfor common conditions such as heart attacks, heart failure and pneumonia. For each condition, there are multiple process measures that, when added up, help tell you about the quality of care at a hospital. These measures are based on research and are widely accepted.
Core measures help identify which aspects of a hospital's care need improving, and they can give you important insights into a hospital's ability to manage specific aspects of a disease.
Example of a core performance measure set: treatment for a heart attack
A patient who is in a hospital because of a heart attack has treatments such as medication to address pain and actions to unclog, or open up, the artery feeding the heart muscle. The core measures look at whether that patient received appropriate related drugs, education and testing, and whether these actions occurred within certain time frames.
The core measure score tells what percentage of the patients who came to the hospital for a heart attack within a certain time frame (usually broken down by three months of the year) received all the right tests and treatments at the right times.
Rush's core measures results
In addition to the quality of care information available, people can use patient experiences with a hospital to help them make their own choices when picking a hospital. The Hospital Consumer Assessment of Healthcare Providers and Systems(HCAHPS, pronounced H-CAPS) hospital survey, administered by the Centers for Medicare and Medicaid Services, provides people with detailed information about adult patients' inpatient experiences for almost every hospital in the United States.
Rush's patient satisfaction results
Mortality rates by condition
Mortality (or death) rates by condition show whether patients who enter a hospital for a particular condition are still alive 30 days after their initial admission to the hospital. Data on 30-day mortality rates are publicly available online from the Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare and Medicaid. Because some hospitals, such as academic medical centers like Rush, tend to take care of significantly sicker patients and more complicated cases, the rate of mortality is adjusted to take into account how sick patients were before being admitted to the hospital. This rate is then referred to as "risk adjusted."
Rush's mortality rates by condition
Mortality rates by service (observed-to-expected)
Mortality observed to expected (o/e) is the risk-adjusted measure of a hospital's mortality (death) rate. Risk adjustment takes into account how sick patients are upon entering the hospital. (See more on risk adjustment below.) The mortality observed-to-expected measure tells us how we are performing on mortality relative to what is expected for our patients, given a variety of complicating characteristics, including their age, chronic conditions like diabetes or heart failure, or whether the patient was transferred from another hospital or admitted as an emergency.
This measure is created from two different numbers:
1) Observed mortality rate, which is measured as the percent of patients who die during their hospital stay. An example of this rate is 50 deaths among 5000 patients, or 1 percent observed mortality.
2) Expected mortality, which adjusts for how sick or complex our patients are compared with patients seen at other hospitals in the country. The national average is used as a starting point and then adjusted higher or lower depending on the complicating characteristics of our patients.
Why do we need risk adjustment?
Healthier patients who come to the hospital for elective procedures have a much lower risk of death than patients who come to the hospital for life-threatening emergencies. Risk adjustment is a statistical process for estimating what percent of patients might die, given how sick they are. Without risk adjustment, we cannot accurately compare our performance with other hospitals.
How is the observed-to-expected (o/e) ratio calculated?
The ratio is calculated by dividing the observed death rate by the expected death rate. If the observed rate is 2 percent and expected rate is 3 percent, the o/e ratio is 2/3, which equals 0.66. The observed-to-expected ratio tells us whether more patients or fewer patients died in the hospital than what’s expected based on how sick the patients were. If this ratio is less than one, it means fewer patients died than expected. If the ratio is greater than one, it means more patients died than expected. A ratio of one means the performance on mortality rate is as expected. For example, an o/e ratio of 0.75 tells us that 25 percent fewer patients died in the hospital than expected. Similarly, an o/e ratio of 1.30 tells us that 30 percent more patients died than expected. Hospitals set goals to achieve a specific o/e ratio based on their own past performance.
Who calculates the mortality measure?
The University HealthSystem Consortium (UHC) is an alliance of academic medical centers and their affiliated hospitals representing approximately 90 percent of the nation’s not-for-profit academic medical centers. UHC performs risk-adjustment calculations for all hospitals and provides reports to the participating hospitals.
Rush's mortality rates by service
Readmission rates show whether patients who enter a hospital for a particular condition are readmitted to the hospital within 30 days after an initial discharge. Data on 30-day readmission rates are publicly available online from the Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare and Medicaid. Because some hospitals, such as academic medical centers like Rush, tend to take care of significantly sicker patients and more complicated cases, the rate of readmissions is adjusted to take into account how sick patients were before being admitted to the hospital. This rate is then referred to as "risk adjusted."
Patient safety indicators
The Agency for Healthcare Research and Quality (AHRQ), run by the U.S. Department of Health and Human Services, developed patient safety indicators to measure potential inpatient complications following certain procedures. Although not all the complications identified in these indicators are preventable, the process of monitoring patient safety indicators shows hospitals where to focus their attention for further review.
Rush's patient safety indicator results
Central line-associated blood stream infection rates
A central line-associated bloodstream infection is a type of infection that is associated with having a catheter inserted in a major vein, usually for the delivery of medications, nutrition or fluids. Bloodstream infections are often serious enough to cause a longer hospital stay or even death. These can be prevented through proper management of the central lines and the removal of these lines when they are no longer needed.
How are central line-associated bloodstream infections measured?
The standardized infection ratio is a summary measure used to compare the central line-associated bloodstream infection experience among one or more groups of patients to a standard population. Similar to how mortality observed to expected is calculated, the standardized infection ratio is the observed number of infections divided by the expected number of infections. The expected number of infections is based on data from the National Healthcare Safety Network, a health care safety surveillance system managed by the Centers for Disease Control and Prevention.
How does Rush monitor central line-associated bloodstream infections?
At Rush, we have implemented checklists to guide sterile insertion of the central lines, and we are using crew resource management, or team training, to check daily whether the lines can be removed. We are also starting a “scrub the hub” campaign for proper maintenance and use of the central line ports.
Rush's central line-associated blood stream infection ratios
These sites further explain quality care and how to seek it:
Cancer quality data
We’re committed to sharing quality data on our cancer care and to continuing to add further measures of quality in the future. We currently have available cancer mortality data and volumes (or the number of cancer cases seen at Rush).
Rush's cancer quality data
Orthopedics quality data
Rush is committed to sharing quality data on our orthopedic care and to continuing to add further measures of quality in the future. We currently have available our joint and spine mortality data and volumes (or the number of surgical cases).
Rush's orthopedics quality data
Heart quality data
Rush is committed to sharing quality data on our heart care and to continuing to add further measures of quality in the future. We currently have available measures for the care of heart attack and heart failure patients.
Rush's heart quality data
Surgical patient outcomes
The American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP) is an outcomes-based program to measure and improve the quality of surgical care across surgical specialties. As a participant in the program, Rush University Medical Center is required to track the outcomes of inpatient and outpatient surgical procedures and collect data that is used to help improve patient safety and quality of surgical care.
This program provides risk-adjusted data. Because some hospitals, such as academic medical centers like Rush, tend to take care of significantly sicker patients and more complicated cases, the rate of mortality is adjusted to take into account how sick patients were before being admitted to the hospital. This rate is then referred to as "risk adjusted."
Surgical patient outcomes