Quality Report Card
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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.

Reportable Events

What we are measuring and why?

Nevada law defines a reportable event as an unexpected occurrence involving physical or psychological injury not related to the natural course of the patient’s illness or underlying condition. (NRS 439.830). These reportable occurrences can include environmental or criminal situations that occur on property in which harm may occur.

Centers for Medicare and Medicaid Services (CMS) define certain hospital-acquired conditions (HACS) resulting in a complicating condition that could reasonably have been prevented through application of evidence-based guidelines.

At University Medical Center, reporting reflects our total patient group (including Medicare and Medicaid recipients). Our priorities are patient safety, patient satisfaction and high quality care delivered in a healing, compassionate environment. We constantly assess and monitor quality and performance seeking improvements based on goals related and compared with our peers nationally.

Measure

Current Performance Reporting Period - 2011

Comparison Group
Currently there is no national benchmark or target for these measures

Behavioral Event

0

N/A

Complications

2

N/A

Fall 1 N/A
Pressure Ulcer 9 N/A

Safe Care Related Event

2

N/A

Surgical/Procedure Related

3

N/A

Behavioral Event

This category may include:

  • Attempted or actual suicide
  • Elopement resulting in death or injury with permanent loss of function

Complications

This category may include:

  • Air Embolism – Unexpected post surgical event associated with air bubble blocking lung blood flow that may lead to major complication including death.
  • Blood Incompatibility – Blood product may cause a transfusion reaction resulting major harm
  • Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) – DVT is a blood clot that forms, usually in the legs. PE a clot that blocks a lung vessel. Both can cause permanent damage and or death. (Click to Read more Details...)

    Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)

    A deep vein thrombosis (DVT) is a blood clot that forms in a deep vein, usually in the legs. A pulmonary embolism (PE) is a condition that occurs when a clot blocks a lung blood vessel. In most cases, a PE is caused by a blood clot that forms in the limbs (DVT), becomes dislodged and travels to the lungs blocking blood flow.

    PE and DVT are serious potential complications of any surgery. All are not preventable but some are. The goal is to minimize the number of preventable DVTs and PEs.

    At University Medical Center, procedures are in place to help prevent these complications. Doctors prescribe patients blood thinning medication (anticoagulants) and/or have patients wear compression sleeves. The medication thins the blood, and compression sleeves squeeze the legs to keep the blood flowing. Additionally, post-operative movement such as walking is encouraged as much as tolerated. Nursing and physician education have focused on prevention of DVT and PE utilizing a team approach.

    What they are
    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.

    Many patients also receive blood-thinning medication, which helps prevent clots from forming. When your doctor allows walking, do so as much as you can. Walking will help prevent clots from forming.


Fall

This category may include:

Patient Fall with Injury
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. At UMC, we look at all patient falls, with and without injury, in order to analyze the event and determine what can be done to reduce and prevent falls and injury. While not all patient falls are preventable, every hospital seeks to reduce or eliminate the risk of patient falls.

PREVENTABLE COMPLICATIONS (PATIENT INFORMATION)

If you are a patient at UMC, you should know you can partner with UMC staff to help prevent the most common complications:

What they are
Patients sometimes fall because they are weak or dizzy, or they trip on equipment in the room


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.

Pressure Ulcer

Pressure ulcer (bed sore) – facility acquired stage III or IV wounds that may result in longer hospitalization and wound treatment. 

Pressure Ulcer (Bedsore)
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. Early identification of at risk patients and frequent inspection of skin and regular assistance with repositioning can successfully prevent and treat pressure ulcer risk and complication. While some patients have higher risk than others, complications of pressure ulcer may be preventable. A lower rate may indicate a hospital provides a higher level of patient care.

What they are
Bedsores or pressure ulcers are areas of skin breakdown that result from lying in one position too long. Bedsores may become infected and may lead to longer hospital stays and can cause serious harm.

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.

Safe Care Related Event

This category may include:

  • Electric shock
  • Discharge to the wrong family/caregiver
  • Contaminated product/device
  • Crush Injury – Unanticipated event not related to underlying condition or treatment resulting in major permanent loss of function or death
  • Blood Sugar management control – uncontrolled blood sugar resulting in major complication such as diabetic ketoacidosis, kidney injury, or death. ( Click to Read more Details...)

Diabetic or kidney problems (blood sugar control)

Current research shows patients heal faster with fewer complications after surgery when the patients’ blood sugar and fluids are carefully managed. This measure identifies patients who suffered uncontrolled blood sugar or harm to their kidneys. It is our goal to improve patient outcomes and minimize the number of patients who experience physiologic/metabolic derangements.

Diabetic or kidney complications can be life-threatening and generally are not expected as complications. While some patients have higher risks than other, some of these complications may be preventable. A lower rate may indicate that a hospital provides a higher level of patient care.

Surgical/Procedural Related

This category may include:

  • Foreign/Retained objects associated with surgical and other procedures ( Click to Read more Details...)


    Equipment left in body during surgical procedure

    During medical and surgical procedures, surgical equipment or material, like sponges, wires or instruments, may be left inside patients’ bodies. Under certain circumstances this is intentional and part of the procedure or course of therapy. Rarely, this is not the intention.

    When foreign bodies are left inside patients, serious complications can occur...

    Every hospital strives to eliminate the risk of retained foreign body. At University Medical Center, procedures are in place to account for all instruments, sponges, and other materials utilized during surgical procedures. Systematic counts and recounts are used to verify all foreign bodies are removed before surgery is complete.


  • Surgical Burns
  • Other Burns (hot liquids)

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.

Currently there is no national benchmark or target. The Joint Commission indicates whether a hospital has met or not met the National Patient Safety Goal and Centers for Medicare and Medicaid Services (CMS) .

Measure Current Performance Reporting Period - 2011 Comparison Group
Improve the accuracy of patient identification The organization has met the National Patient Safety Goal Met goal per The Joint Commission and Centers for Medicare and Medicaid Services (CMS)
Improve the effectiveness of communication among caregivers The organization has met the National Patient Safety Goal Met goal per The Joint Commission and Centers for Medicare and Medicaid Services (CMS)
Improve the safety of using medications The organization has met the National Patient Safety Goal Met goal per The Joint Commission and Centers for Medicare and Medicaid Services (CMS)
Reduce the risk of healthcare associated infections The organization has met the National Patient Safety Goal Met goal per The Joint Commission and Centers for Medicare and Medicaid Services (CMS)
The organization identifies safety risks inherent in its patient population. The organization has met the National Patient Safety Goal Met goal per The Joint Commission and Centers for Medicare and Medicaid Services (CMS)
Universal Protocol The organization has met the National Patient Safety Goal Met goal per The Joint Commission and Centers for Medicare and Medicaid Services (CMS)

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 99 100
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) 93 100
Heart attack patients given beta blocker at discharge 99 100
Heart attack patients given Percutaneous Coronary Intervention (PCI) within 90 min. of arrival 88 100
Heart attack patient prescribed a Statin at discharge 97 100
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 discharge instructions 80 97
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) 97 100
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 84 100
Patients with weaker immune systems given the right kind of antibiotics 97 100
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 86 97
Outpatients having surgery who got the right kind of antibiotics 96 97
Surgery patients taking beta blockers were kept on medications 88 100
Surgery patients given antibiotic at right time 93 100
Surgery patients given the right kind of antibiotics 94 100
Surgery patients given antibiotics for prevention stopped at the right time 94 99
Heart surgery patients whose blood sugar is kept under good control 81 99
Surgery patients needing hair removed had safer method (to minimize infection) 99 100
Surgery patients whose doctors ordered treatment to prevent blood clots 99 100
Surgery patients who got treatment to prevent blood clots at right time 92 100
Surgery patients whose urinary catheters were removed on the first or second day after surgery 74 96
*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. 0.057 0.149
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. 0.118 0.044
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. 5.9 5.6
*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.

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