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Quality
Improvements Home
JC Accreditation
OSF St. Mary a Quality Leader
Patient Satisfaction and Service Quality
Quality Reports
Saving
5 Million Lives
Hospital
Report Card Act
OSF St. Mary Medical Center Quality Improvement
OSF
St. Mary Medical Center is dedicated to providing the highest
quality and safest patient care in the region. Our Quality Improvement
process involves staff from throughout the medical center including
physicians, nurses, pharmacists, emergency and trauma service staff, as
well as critical and intensive care departments.
Quality
Improvement services include coordinating activities such as:
- Incident
reporting
- Root cause
analysis
- Effects
analysis
- National
patient safety goals
- Education and
awareness
- Coordination
of quality / performance improvement initiatives
- Management of
the Peer Review process
- Facilitation
of the Quality Reviews / Morbidity and Mortality Reviews
- Quality
indicator monitoring, benchmarking and reporting to numerous internal
and external databases
- Coordination
of JC and other regulatory compliance
- Clinical data
analysis
- Providing
staff support and education on quality and patient safety issues.
Public Information About OSF St.
Mary
Quality
One of the steps OSF St. Mary has taken to provide the public with
information about the quality of the care we provide is by participating
in the Healthcare Quality Alliance, which is a collaborative effort
between the Centers for Medicare & Medicaid Services, national hospital
organizations, accrediting organizations, consumer advocates and others.
OSF St. Mary
was one of the first hospitals in the country to participate in this
effort to improve care and make more information available to the
public. Many hospitals have been providing information through this
initiative since November 2003.
Below are the
results of the most recent data we reported to the Alliance. It and
information from other hospitals can be found at
http://www.hospitalcompare.hhs.gov/hospital/home2.asp.
The state and
national percentages displayed below are derived from the medical record
data submitted by hospitals to the QIO Clinical Data Warehouse.
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Quality Measures
Data collected nationally from Hospitals submitting data to QIO
Data Warehouse
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Average for all reporting hospitals in the United States
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Average for all reporting hospitals in the state of Illinois
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OSF ST. MARY
MEDICAL CENTER
GALESBURG, IL
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|
Heart Attack
(AMI) Care
|
| ACE
Inhibitor for LVSD |
85%
|
84%
|
4/6*
|
| Aspirin at
arrival |
93%
|
93%
|
87%
|
| Aspirin at
discharge |
90%
|
90%
|
85%
|
| Beta blocker
at arrival |
88%
|
88%
|
71%
|
| Heart Attack
Patients Given Adult Smoking Cessation Advice/Counseling |
91%
|
91%
|
9/9*
|
| Beta blocker
at discharge |
91%
|
89%
|
90%
|
|
Heart Failure
Care
|
| ACE
Inhibitor for LVSD |
84%
|
85%
|
92%
|
| Assessment
of Left Ventricular Function |
85%
|
90%
|
97%
|
| Heart
Failure Patients Given Adult Smoking Cessation Advice/Counseling |
86%
|
86%
|
100%
|
| Heart
Failure Patients Given Discharge Instructions |
66%
|
71%
|
84%
|
|
Pneumonia Care
|
| Pneumonic Patients Assessed and
Given Influenza Vaccination |
75% |
71% |
95% |
| Initial
Antibiotic Timing |
93%
|
94%
|
96%
|
| Oxygenation
assessment |
99%
|
99%
|
100%
|
| Pneumococcal
Vaccination |
75%
|
71%
|
93%
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| Pneumonia
Patients Having a Blood Culture Performed Prior to First Antibiotic
Received in Hospital |
90%
|
90%
|
86%
|
| Pneumonia
Patients Given the Most Appropriate Initial Antibiotic(s) |
86%
|
86%
|
90%
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| Pneumonia
Patients Given Adult Smoking Cessation Advice |
84%
|
84%
|
95%
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Surgical
Infection
|
| Surgery
Patients Who Received Preventative Antibiotic(s) One Hour Before
Incision |
82%
|
79%
|
96%
|
Surgery Patients Who Received
Appropriate Preventative
Antiobiotic(s) |
90% |
91% |
96% |
| Surgery
Patients Whose Preventative Antibiotic(s) are Stopped Within 24
hours After Surgery |
78%
|
74%
|
87%
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Survey of Patients' Hospital Experiences
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| How often
did nurses communicate well with patients? |
| Nurses "always" communicated well |
73%
|
73%
|
79%
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| Nurses "usually" communicated well |
21%
|
21%
|
19%
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| Nurses "sometimes" or "never" communicated well |
6%
|
6%
|
2%
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| How often did doctors communicate well with patients? |
| Doctors "always" communicated well |
79%
|
80%
|
85%
|
| Doctors "usually" communicated well |
16%
|
15%
|
13%
|
| Doctors "sometimes" or "never" communicated well |
5%
|
5%
|
2%
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| How often did patients receive help quickly from hospital staff? |
| Patients "always" received help as soon as they wanted |
60%
|
60%
|
70%
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| Patients "usually" received help as soon as they wanted |
28%
|
27%
|
26%
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| Patients "sometimes" or "never" received help as soon as they wanted |
12%
|
13%
|
4%
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| How often was patients' pain well controlled? |
| Pain was "always" well controlled |
67%
|
68%
|
71%
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| Pain was "usually" well controlled |
25%
|
24%
|
24%
|
| Pain was "sometimes" or "never" well controlled |
8%
|
8%
|
5%
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| How often did staff explain about medicines before giving them to patients? |
| Staff "always" explained |
58%
|
57%
|
57%
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| Staff "usually" explained |
18%
|
18%
|
23%
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| Staff "sometimes" or "never" explained |
24%
|
25%
|
20%
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| How often were the patients' rooms and bathrooms kept clean? |
| Room was "always" clean |
68%
|
69%
|
75%
|
| Room was "usually" clean |
21%
|
21%
|
19%
|
| Room was "sometimes" or "never" clean |
11%
|
10%
|
6%
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| How often was the area around patients' rooms kept quiet at night? |
| "Always" quiet at night |
54%
|
53%
|
59%
|
| "Usually" quiet at night |
32%
|
32%
|
31%
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| "Sometimes" or "never" quiet at night |
14%
|
15%
|
10%
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| Were patients given information about what to do during their recovery at home? |
| Yes, staff did give patients this information |
79%
|
79%
|
74%
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| No, staff did not give patients this information |
21%
|
21%
|
26%
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| How do patients rate the hospital overall? |
| Patients who gave a rating of "9" or "10" (high) |
63%
|
62%
|
78%
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| Patients who gave a rating of "7" or "8" (medium) |
26%
|
27%
|
16%
|
| Patients who gave a rating of "6" or lower (low) |
11%
|
11%
|
6%
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| Would patients recommend the hospital to friends and family? |
| YES, patients would definitely recommend the hospital |
67%
|
66%
|
79%
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| YES, patients would probably recommend the hospital |
27%
|
28%
|
19%
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| NO, patients would not recommend the hospital (they probably would not or definitely would not recommend it) |
6%
|
6%
|
2%
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Data Last
Updated: March 21, 2008
* When less than 25
cases are reported, rather than presenting percentages, the number of
cases meeting this criterion are in the numerator of the ratio and the
denominator represents the total number of patients in the category.
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