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Quality Reports
Overview
OSF St. Francis Hospital & Medical Group is dedicated to providing the highest quality and safest patient care in the region. Our Quality Improvement process involve 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
- Failure mode 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. Francis Quality
One of the steps OSF St. Francis 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. Francis 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/.
The state and national percentages displayed below are derived from the medical record data submitted by hospitals to the QIO Clinical Data Warehouse.
| Quality Measures data collected nationally from Hospitals submitting data to QIO Data Warehouse |
Average for all reporting hospitals in the United States |
Average for all reporting hospitals in the state of Michigan | OSF ST. FRANCIS HOSPITAL & MEDICAL GROUP |
| Heart Attack (AMI) Care |
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| ACE Inhibitor or ARB for LVSD |
91% | 93% | 10/11* |
| Aspirin at arrival |
94% | 96% | 90% |
| Aspirin at discharge |
93% | 93% | 96% |
| Heart Attack Patients Given Adult Smoking Cessation Advice/Counseling |
96% | 94% | 2/2* |
| Beta blocker at discharge |
94% | 95% |
93% |
| Heart Failure Care |
|||
| ACE Inhibitor or ARB for LVSD |
89% | 90% | 89% |
| Assessment of Left Ventricular function |
90% | 95% | 95% |
| Heart Failure Patients Given Adult Smoking Cessation Advice/Counseling |
92% | 96% | 9/9* |
| Heart Failure Patients Given Discharge Instructions |
77% | 84% | 91% |
| Pneumonia Care | |||
| Pneumonic Patients Assessed and Given Influenza Vaccination | 85% |
88% | 95% |
| Initial Antibiotic Timing |
93% | 95% | 97% |
| Pneumococcal Vaccination |
85% | 88% | 97% |
| Pneumonia Patients Having a Blood Culture Performed Prior to First Antibiotic Received in Hospital |
92% | 93% | 97% |
| Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s) | 88% | 92% | 95% |
| Pneumonia Patients Given Adult Smoking Cessation Advice/Counseling |
90% | 92% |
96% |
| Surgical Care Improvement Project |
|||
| Surgery patients taking beta blockers before coming to the hospital who were kept on them during the period before and after their surgery |
87% | 90% | 6/6* |
| Surgery Patients Who Received Preventative Antibiotic(s) One Hour Before Incision |
90% | 93% | 95% |
| Surgery Patients Who Received Appropriate Preventative Antibiotic(s) | 94% | 95% | 99% |
| Surgery Patients Whose Preventative Antibiotic(s) are Stopped Within 24 Hours After Surgery | 89% | 92% |
99% |
| Heart Surgery Patients Whose Blood Sugar is Kept Under Control Before Surgery | 87% | 88% | 0/0* |
| Surgery Patients Who Needed Hair Removed From Surgical Area Using Safer Removal Methods (Clippers or Cream, no Razors) | 97% | 97% |
100% |
| Surgery Patients Whose Physicians Ordered Blood Clot Treatments After Surgery | 87% | 91% |
97% |
| Patients Who Got Treated for Blood Clots within 24 Hours Before or After Surgery | 85% | 89% |
97% |
| Survey of Patients' Hospital Experiences |
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| How often did nurses communicate well with patients? |
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| Nurses "always" communicated well |
74% | 75% | 80% |
| Nurses "usually" communicated well |
20% | 20% | 17% |
| Nurses "sometimes" or "never" communicated well |
6% | 5% |
3% |
| How often did doctors communicate well with patients? | |||
| Doctors "always" communicated well |
80% | 79% | 84% |
| Doctors "usually" communicated well |
15% | 16% | 14% |
| Doctors "sometimes" or "never" communicated well |
5% | 5% |
2% |
| How often did patients receive help quickly from hospital staff? |
|||
| Patients "always" received help as soon as they wanted |
62% | 65% | 74% |
| Patients "usually" received help as soon as they wanted |
26% | 26% |
22% |
| Patients "sometimes" or "never" received help as soon as they wanted |
12% |
9% |
4% |
| How often was patients' pain well controlled? |
|||
| Pain was "always" well controlled |
68% | 69% | 76% |
| Pain was "usually" well controlled |
24% | 24% | 20% |
| Pain was "sometimes" or "never" well controlled |
8% | 7% |
4% |
| How often did staff explain about medicines before giving them to patients? |
|||
| Staff "always" explained |
59% | 58% | 61% |
| Staff "usually" explained |
18% | 19% | 19% |
| Staff "sometimes" or "never" explained | 23% | 23% |
20% |
| How often were the patients' rooms and bathrooms kept clean? | |||
| Room was "always" clean |
70% | 69% | 75% |
| Room was "usually" clean | 20% | 22% | 18% |
| Room was "sometimes" or "never" clean |
10% | 9% |
7% |
| How often was the area around patients' rooms kept quiet at night? | |||
| "Always" quiet at night |
56% | 54% | 47% |
| "Usually" quiet at night |
31% | 33% | 40% |
| "Sometimes" or "never" quiet at night |
13% | 13% |
13% |
| Were patients given information about what to do during their recovery at home? |
|||
| Yes, staff did give patients this information | 80% | 82% | 85% |
| No, staff did not give patients this information |
20% | 18% |
15% |
| How do patients rate the hospital overall? |
|||
| Patients who gave a rating of "9" or "10" (high) |
65% | 67% | 64% |
| Patients who gave a rating of"7" or "8" (medium) | 25% | 24% |
27% |
| Patients who gave a rating of "6" or lower (low) |
10% | 9% |
9% |
| Would patients recommend the hospital to friends and family? |
|||
| YES, patients would definitely recommend the hospital |
68% | 69% | 64% |
| YES, patients would probably recommend the hospital |
26% | 26% | 31% |
| NO, patients would not recommend the hospital (they probably would not or definitely would not recommend it) |
6% | 5% |
5% |
Data Last Updated: November 23, 2009
*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.
