Quality Report Card
  • Home
  • Patient Safety
  • Cardiovascular Care
  • Medical Care
  • Surgical Care
  • Outpatient Care
  • FAQS

What Quality Means to Us

Welcome to the University Medical Center health care data reporting site. To us, quality means delivering care that is effective, safe, coordinated, timely and convenient. To find out if we are achieving quality care, we constantly measure our healthcare performance by collecting hundreds of quality measures. We make our Quality Report Card public to let you know how we measure up to national healthcare quality comparisons.

Our Performance

Every detail counts when it comes to providing the highest quality care that is safe and error free. At UMC we are committed to sharing our quality and safety results with the community we serve. This site provides comparative data about UMC quality and safety.

Understanding Reports

At UMC, it is our goal to present comparative data in easy to understand format. Our data is nationally compared to similar hospitals. Data is also compared to government requirements.

Patient Safety and Quality Improvement

University Medical Center is an academic medical center where the patient comes first. Our top priorities are quality and patient safety. We are committed to delivering the highest level of quality and safe, personalized care for every patient we serve. At UMC we use recognized criteria for ongoing review of our performance in an effort to reduce potentially avoidable risk for our patients.

National Patient Safety Goals

At University Medical Center, quality is validated and accredited by The Joint Commission. The Joint Commission’s National Patient Safety Goals program provides a significant focus on patient safety specifically targeting several of the most pressing patient safety issues in the nation. Oversight of the National Patient Safety Goals process is rigorous and is a critically important component of The Joint Commission’s overall efforts to improve health care.

At University Medical Center, National Patient Safety Goals provide focus for some of the most important safety initiatives. The Joint Commission evaluates UMC on our organizational improvement activities and achievement of patient safety initiatives.

Learn more about National Patient Safety Goals and see how University Medical Center meets The Joint Commission standards.

For all measures below, UMCSN has meet the goals per the Joint Commission and Centers for Medicare and Medicaid Services (CMS)

Measure

Improve the accuracy of patient identification

Improve the effectiveness of communication among caregivers

Improve the safety of using medications

Alarms used safely on medical equipment

Reduce the risk of healthcare associated infections

The organization identifies safety risks inherent in its patient population.

Universal Protocol

Cardiovascular Care

Acute Myocardial Infarction (heart attack)
Cardiovascular disease is the leading cause of death in the United States. Acute myocardial infarction is a potentially life-threatening event associated with cardiovascular disease. A patient who suffers a heart attack will have a better chance of survival and experience less heart damage when standards of care are followed. The Joint Commission and heart attack specialists have defined specific actions in this set of standards. Patients tend to have better outcomes when these guidelines are followed.

Data Period: Most Recent Year UMC % Other Academic Hospitals* (UHC) %
Heart attack patients given aspirin on arrival 100 100
Heart attack patients given aspirin upon discharge 98 100
Heart attack patients given Angiotensin Converting Enzyme inhibitors (ACE) or Angiotensin Receptor Blockers (ARB) for Left Ventricle Systolic Dysfunction (LVSD) 92 100
Heart attack patients given beta blocker at discharge 98 100
Heart attack patients given Percutaneous Coronary Intervention (PCI) within 90 min. of arrival 95 100
Heart attack patient prescribed a Statin at discharge 99 100
Mortality (within 30 days of hospitalization) No Different Than U.S. National Rate
Readmission (within 30 days) No Different Than U.S. National Rate
*The University HealthSystem Consortium (UHC), formed in 1984, is an alliance of 107 many other nationally ranked medical centers and 233 of their affiliated hospitals representing approximately 90% of the nation's non-profit academic medical centers. University Medical Center shares UHC membership with Johns Hopkins Medical Center,Cedars-Sinai Medical Centers, Stanford University Hospital, Emory University Hospital, Mayo Clinic Hospitals, and other ranked academic medical centers.

Heart Failure

Cardiovascular disease is the leading cause of death in the United States. Heart failure, also known as Congestive (chronic) Heart Failure or CHF affects 4.8 million people in the United States. Heart failure is the number one diagnosis for Medicare patients. Patients with heart failure are frequently hospitalized due to complications of this disease. The Joint Commission and CMS (Centers for Medicare and Medicaid Services) have defined specific actions that can reduce the incidence of patient risk and hospitalization. Patients tend to have better outcomes when these guidelines are followed.

Data Period: Most Recent Year UMC % Other Academic Hospitals* (UHC) %
Patients given an evaluation for Left Ventricular Systolic (LVS) function 99 100
Patients given an Angiotensin Converting Enzyme inhibitors (ACE) for poor Left Ventricle Systolic Dysfunction (LVSD) 96 100
Mortality (within 30 days of hospitalization) No Different Than U.S. National Rate
Readmission (within 30 days) No Different Than U.S. National Rate
*The University HealthSystem Consortium (UHC), formed in 1984, is an alliance of 107 many other nationally ranked medical centers and 233 of their affiliated hospitals representing approximately 90% of the nation's non-profit many other nationally ranked medical centers. University Medical Center shares UHC membership with Johns Hopkins Medical Center,Cedars-Sinai Medical Centers, Stanford University Hospital, Emory University Hospital, Mayo Clinic Hospitals, and other ranked academic medical centers.

Medical Care

There are many diseases that fall into the category of medical care. The primary diseases of pneumonia, heart failure, and heart attack are included in this group. Research and scientific evidence conclude patients tend to have fewer hospital visits and better outcomes when immunization, antibiotics, and smoking cessation are addressed.

Data Period: Most Recent Year UMC % Other Academic Hospitals* (UHC) %
Patients with initial Emergency Room blood cultures prior to first dose of antibiotics 100 100
Patients with weaker immune systems given the right kind of antibiotics 95 100
Mortality (within 30 days of hospitalization) No Different Than U.S. National Rate
Readmission (within 30 days) No Different Than U.S. National Rate
*The University HealthSystem Consortium (UHC), formed in 1984, is an alliance of 107 many other nationally ranked medical centers and 233 of their affiliated hospitals representing approximately 90% of the nation's non-profit many other nationally ranked medical centers. University Medical Center shares UHC membership with Johns Hopkins Medical Center,Cedars-Sinai Medical Centers, Stanford University Hospital, Emory University Hospital, Mayo Clinic Hospitals, and other ranked academic medical centers.

Surgical Care

Patients undergoing inpatient or outpatient surgery are at a higher risk for complications such as infection, heart problems, blood clots, and blood sugar imbalance. Research and scientific findings show patients tend to do better when a standard set of conditions are met both before and after surgery.

Data Period: Most Recent Year UMC % Other Academic Hospitals* (UHC) %
Outpatients having surgery who got an antibiotic at the right time 91 100
Outpatients having surgery who got the right kind of antibiotics 98 100
Surgery patients taking beta blockers were kept on medications 92 100
Surgery patients given antibiotic at right time 97 100
Surgery patients given the right kind of antibiotics 99 100
Surgery patients given antibiotics for prevention stopped at the right time 94 100
Heart surgery patients whose blood sugar is kept under good control 91 100
Surgery patients needing hair removed had safer method (to minimize infection) 100 100
Surgery patients who got treatment to prevent blood clots at right time 96 100
Surgery patients whose urinary catheters were removed on the first or second day after surgery 88 99
*The University HealthSystem Consortium (UHC), formed in 1984, is an alliance of 107 many other nationally ranked medical centers and 233 of their affiliated hospitals representing approximately 90% of the nation's non-profit many other nationally ranked medical centers. University Medical Center shares UHC membership with Johns Hopkins Medical Center,Cedars-Sinai Medical Centers, Stanford University Hospital, Emory University Hospital, Mayo Clinic Hospitals, and other ranked academic medical centers.

Outpatient Care

Outpatient care at UMC clinics and Quick Care centers provides our community with care based on current best practices. One aspect of care is diagnostic testing which includes MRI and CAT Scan (CT Scan).

Outpatient Imaging

Radiology procedures such as MRI and CAT Scan (CT Scan) can be used to diagnose conditions such as back or neck injury and diseases of body organs such as the liver and lungs. Scientific evidence cautions the overuse of MRI or CT Scan can lead to unnecessary exposure to radiation and contrast materials. In most cases, it is best to first try other tests and treatments, minimizing the potential harmful effects of these tests.

Data Period: Most Recent Year UMC % National Average %
MRI Lumbar Spine for Low Back Pain(%) Outpatients with low back pain who had an Magnetic Resonance Image (MRI) without trying recommended treatments first, such as physical therapy. (A lower number is better, indicating facility is doing only necessary MRIs.) *N/A N/A
Use of Contrast - Abdomen CT Percentage of abdomen studies (Computed Tomography-CT) performed (with and without contrast) out of all abdomen CT studies done. The range for this measure is 0 to 1. A lower number, in most cases, is better indicating a single scan is all that is needed, minimizing potential harmful effects of radiation and contrast exposure. .062 .105
Use of Contrast - Thorax CT Percentage of chest studies (Computed Tomography-CT) performed (with and without contrast) out of all chest CT studies done. The range for this measure is 0 to 1. A lower number, in most cases, is better indicating a single scan is all that is needed, minimizing potential harmful effects of radiation and contrast exposure. .151 .027
Use of cardiac imaging – Stress Echocardiography, Myocardial Perfusion Imaging (SPECT MPI) or Stress Magnetic Resonance Imaging (MRI) studies performed at a hospital outpatient facility anywhere in the 30 days prior to an outpatient, low-risk, non-cardiac surgery. 3.7 5.3
Imaging (MRI) studies performed at a hospital outpatient facility anywhere in the 30 days prior to an outpatient, low-risk, non-cardiac surgery.
*Number of cases too small for reliable hospital performance outcome.

Frequently Asked Questions

Listed below are some of the most common questions from our patients.

What are Patient Falls?

A patient fall is an unplanned descent to the floor with or without injury. The fall or slip can occur when the patient attempts to get out of bed without assistance and is dizzy, weak or confused.

What you can do to prevent falls
Don’t get out of bed without staff assistance. We want to help you move safely about your room. Even a quick trip to the bathroom can be a safer activity with help from a UMC staff member.

What are Bedsores?

A pressure ulcer or bedsore is an area of skin injury or breakdown that can occur when people lie in one position for an extended period of time. Injury can occur in as little as a few hours of lying in one position without turning or shifting. These wounds can be uncomfortable, and can also become infected, leading to further complications including longer hospital stays.

What you can do to prevent bedsores
UMC staff evaluates patient skin and assists with frequent turning. If you are unable to move, the staff will help you turn every two hours or more often. If you cannot move by yourself, your family can help by reminding the staff to help you turn and to examine your skin closely.

What are Blood Clots?

Hospitalized patients are often inactive, which can cause blood in the vessels to slow down and clot. A clot can form and block a blood vessel, a condition called deep vein thrombosis (DVT). A clot can break free, travel to the lungs and block blood flow in your lungs. This is called pulmonary embolus (PE). These blood flow clots are serious and can be life threatening.

What you can do to prevent blood clots
Follow your doctor’s recommendation for activity level while in UMC. Your doctor may order compression sleeves, which inflate and deflate to help keep blood flowing in your legs. Keep them on as directed, they will help prevent blood clots from forming.