Measurement & Feedback
What are Core Measures?
Core Measures track a variety of evidence-based, scientifically researched standards of care which have been shown to result in improved clinical outcomes for patients. The Center for Medicare & Medicaid Service (CMS) established the Core Measures in 2000 and began publicly reporting data about the Core Measures in 2003. Compliance with Core Measures interventions by hospital staff helps to provide optimal care to our patients. Emerson Hospital tracks its compliance with evidence-based interventions aimed at reducing: surgical infection, acute myocardial infarction (heart attack), heart failure and pneumonia. In each of these sections, we discuss these measures and why they are relevant to you as a patient. Additionally, we provide a graph of our performance. Graphical data is of July 2012.
Current Quality Initiatives
Emerson Hospital measures the 30-day readmission rate for heart failure (HF), acute myocardial infarction (AMI) and pneumonia (PNE) as these rates are being reported publicly for Medicare patients. Beginning in 2013, hospitals with high readmission rates will receive reduced payments from Medicare. Studies have shown that 20% of Medicare beneficiaries who are discharged from the hospital are re-hospitalized within 30 days and that expenditures for potentially preventable re-hospitalizations may be as high as $12 billion a year. Our goal is to reduce 30-day readmissions over time by 10% in order to improve the quality of patient care and patient satisfaction and to prepare for potential changes in payment.
We are piloting several programs aimed at reducing 30-day readmission rates for patients at high risk of readmission, including participating in the State Action on Avoidable Rehospitalizations (STAAR) initiative. This is an Institute for Healthcare Improvement collaborative supported by The Commonwealth Fund. As part of STAAR, we are implementing inpatient unit-based pilots to perform enhanced admission assessments for post-hospital needs, provide effective teaching and enhanced learning, conduct real-time communications handoffs, and ensure post-hospital care follow-up..
National Surgical Quality Improvement Project
The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is the first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. The program employs a prospective, peer-controlled, validated database to quantify 30-day risk-adjusted surgical outcomes. This allows for meaningful comparison of outcomes among all hospitals in the program. A surgical nurse reviewer works closely with surgeons and patients to analyze outcomes. In so doing, improvements in process are identified to minimize surgical complications and ensure the best outcomes. Participating hospitals and their surgical staff are provided with the tools, reports, analysis and support necessary to make informed decisions about improving quality of care. Institute of Medicine named NSQIP “the best in the nation” for measuring and reporting surgical quality and outcomes.
In December of 2007, Emerson Hospital began participating in NSQIP. Most of the General Surgery and Vascular Surgery procedures performed at Emerson are included in the program. The unique aspect of NSQIP is that our patient’s outcomes are followed out to 30 days after their surgery. This allows patients to have a dialogue with nursing staff about the outcome of their surgery and to explain any symptoms they may be experiencing. In some cases, follow-up care to ensure the most successful recovery process is arranged based on that interaction. This has received very positive feedback from both physicians and patients.
Safety Measures (Falls, Pressure Ulcers)
PatientCareLink is a voluntary initiative in which Massachusetts hospitals participate to illustrate their commitment to provide the safest levels of high-quality care. The Patients First platform commits hospitals to work collaboratively to create practices and innovations to enhance excellence in patient care. Hospitals embraced new strategies to reduce medical errors, increase safety and efficiency, open up communications and increase transparency by publicly reporting data about falls, pressure ulcers and staffing at their institutions. Best practices are shared among participants with the goal of eliminating their recurrence wherever possible.
View Emerson’s PatientCareLink's data performance
Patient Satisfaction Data
After they are discharged, Emerson patients are asked to participate in satisfaction surveys sent to them by mail. The HCAHPS® (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is composed of a variety of questions about aspects of the hospital experience. It is a national survey required of all acute hospitals receiving Medicare funding. It is also a way to compare patient satisfaction across hospitals locally, regionally and nationally.
Patients provide their opinions on their communication with doctors, communication with nurses, responsiveness of hospital staff, cleanliness and quietness of hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital and recommendation of hospital.
Emerson is particularly proud of patient responses to the question “Would you recommend this hospital to family and friends?” The graph below illustrates that Emerson Hospital performs better than the national average on this particular question.
Footnote 11: The hospital indicated that the data submitted for this measure were based on a sample of cases.
Here’s what some patients think of the quality of care while at Emerson:
“I was admitted for two procedures, am 27 years-old and this was my very first hospital experience. I was so impressed with all the staff at the hospital; from the doctors to the nurses to the volunteers. Everyone was absolutely wonderful, caring and attentive and made what could have been a nightmare a very wonderful experience. I am just incredibly grateful and impressed!”
— Sara, Dedham
“My husband and I found out just how good Emerson is, when my husband was admitted with pneumonia. He was transferred from the Emergency Department to Wheeler 4. From the very first day until he was transferred to the Transitional Care Unit, the nurses and nurse technicians worked tirelessly, with compassion and caring to make my husband comfortable. Thank you for all the hard work and kindness that was shown to me as well.”
— Doris and John, Concord
“Our son Ryan, age 17, underwent an appendectomy. In the PACU, he had a very frightening complication. The grandest accolades need to be given to Candace and Stephanie in the PACU. Candace demonstrated complete professionalism and we knew right away that our son was in extremely competent and capable hands. There aren’t enough words to express how grateful we are to have such top notch care just minutes from home. Ryan is back in school and doing wonderfully!”
— Tom and Cheri, Maynard
Complaint/Feedback Submission Process
At Emerson, we are committed to personalized, excellent care for our patients. And our workforce is devoted to providing the safest and highest quality care available. We further commit to service excellence in all that we do.
However, we recognize that there may be circumstances where we did not deliver on our commitment to you. If you have concerns, problems or complaints about patient safety, the quality of care or service that you or a patient received in our care, you are encouraged to speak directly to the providers, or appropriate supervisors or management staff.
In circumstances where your concerns are not resolved to your satisfaction, our Service Excellence Coordinator is available to listen and facilitate resolution.
Concerns regarding patient care and safety may be communicated to Emerson’s Quality and Patient Safety Department via telephone at (978) 287-3203 or (978) 287-3095, Monday - Friday, 8:30 am – 5:00 pm.
After hours, please leave a confidential voice mail message and your call will be returned promptly.
If you feel that your concerns have not been resolved by our organization, you may contact The Joint Commission, our accrediting body:
Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181