We are constantly scanning national resources to identify valid and reliable measures of hospital quality. Our quality committees review and approve measures which meet these criteria:
- They must be meaningful measures to evaluate and improve patient care
- They must be valid and reliable based on scientific and expert consensus
- They must use a methodology or formula for calculation that is public and transparent
We use many comparisons to challenge ourselves to achieve the highest level of performance. Below is a list of the comparisons we use for our Quality Rating.
ACC - NCDR: American College of Cardiology - National Cardiovascular Data Registry
The National Cardiovascular Data Registry is a voluntary system which allows a hospital to contribute detailed clinical data collected from patient medical records according to common definitions in order to identify opportunities for improvement.
“NCDR® is the recognized resource for measuring and quantifying outcomes and identifying gaps in the delivery of quality cardiovascular patient care in the United States. Its mission is to improve the quality of cardiovascular patient care by providing information, knowledge and tools, implementing quality initiatives; and supporting research that improves patient care and outcomes.”
To learn more, go to the NCDR website.
AHRQ: Agency for Healthcare Research and Quality
The U.S. Agency for Healthcare Research and Quality has developed measures of quality and patient safety by using information found on hospital bills. These measures are considered less reliable than those which are based on intensive review of medical records because the diagnosis and procedure data on bills are not very detailed. However, these measures are very easy and inexpensive to prepare, and they can be one part of an overall review of quality and safety.
“The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) are measures of health care quality that make use of readily available hospital inpatient administrative data…. Inpatient QIs reflect quality of care inside hospitals including inpatient mortality for medical conditions and surgical procedures…Patient Safety Indicators also reflect quality of care inside hospitals, but focus on potentially avoidable complications and iatrogenic events.”
To learn more, go to the AHRQ website.
BOLD: Bariatric Outcomes Longitudinal Database™
The Bariatric Outcomes Longitudinal Database™ is a system which allows a hospital to contribute detailed clinical data collected from patient medical records according to common definitions in order to identify opportunities for improvement. For hospitals that wish to be certified as a Bariatric Center of Excellence, participation is required. Northwestern Memorial Hospital is a Bariatric Center of Excellence.
“Surgical Review Corporation expects more than 100,000 patients to be entered annually into its Bariatric Outcomes Longitudinal Database™ (BOLD™), thus making it the largest bariatric surgery database registry in the world. Each participant in the BSCOE [Bariatric Surgery Centers of Excellence] program is required to submit detailed patient information on every patient that has bariatric surgery.”
To learn more, go to the BOLD website.
CDC - NHSN: U.S. Centers for Disease Control and Prevention: National Healthcare Safety Network
The U.S. Centers for Disease Control and Prevention sponsors a voluntary database to which hospitals may submit information about infections. The data are collected through clinical investigation of medical records according to common definitions. The NHSN also publishes periodic data to help hospitals identify opportunities to improve infection prevention.
To learn more, go to the CDC website.
CMS: Centers for Medicare and Medicaid Services
The U.S. Department of Health and Human Services operates a database of quality measures in hospitals. The quality measures are collected by each hospital through a detailed review of patients’ medical records, according to common definitions, and some may be audited by CMS. Some measures are also collected by surveying patients.
“Welcome to Hospital Compare. In this tool you will find information on how well hospitals care for patients with certain medical conditions or surgical procedures, and results from a survey of patients about the quality of care they received during a recent hospital stay. This information will help you compare the quality of care hospitals provide. Talk to your doctor about this information to help you, your family and your friends make your best hospital care decisions. Hospital Compare was created through the efforts of the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services, and other members of the Hospital Quality Alliance: Improving Care Through Information (HQA). The information on this website comes from hospitals that have agreed to submit quality information for Hospital Compare to make public.”
To learn more, go to the CMS website.
HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems
The Hospital Consumer Assessment of Healthcare Providers and Systems is a survey of patients who have recently used inpatient hospital services administered according to regulations of the Centers for Medicare and Medicaid Services (CMS).
“The intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care…The HCAHPS survey contains 18 patient perspectives on care and patient rating items that encompass eight key topics: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment.”
Source: http://www.hcahpsonline.org. Centers for Medicare & Medicaid Services, Baltimore, MD. July 17, 2012.
To learn more, go to the HCAHPS Online website.
HRCA: Illinois Hospital Report Card Act
The Illinois Hospital Report Card Act, 210 ILCS 86, and its regulations define specific measures of nurse staffing in hospitals. Submission of the data is mandatory in Illinois.
To learn more, go to the Illinois General Assembly website.
The Illinois Department of Public Health (IDPH) is a state agency that promotes the health of people in Illinois through the prevention and control of disease and injury. Consumers can access information and compare hospitals on quality, safety, patient satisfaction, patient volume, length of stay, costs of services, number of beds and pediatric quality measures.
“IDPH has 200 different programs that benefit each state resident and visitor, although its daily activities of maintaining the public's health are rarely noticed unless a breakdown in the system occurs. With the assistance of local public health agencies, these essential programs and services make up Illinois' public health system, a system that forms a frontline defense against disease through preventive measures and education. Public health has provided the foundation for remarkable gains in saving lives and reducing suffering. When using health care facilities in Illinois, patients and their families can be assured quality of care standards have been established to ensure facilities provide health care services in a clean and safe environment that meets their physical, mental and psychological needs.”
To learn more, go to the IDPH website.
The Illinois Hospital Association (IHA) is a state organization that advocates for and supports hospitals and health systems as they serve their patients and communities.
“As the statewide association for more than 200 hospitals and health systems across Illinois, the Illinois Hospital Association advocates on critical health care issues in the General Assembly, the U.S. Congress, and key state and federal agencies. IHA works to continue raising awareness of elected officials and policymakers about the key role that hospitals play as partners with government in supporting and strengthening our health care delivery system. We welcome the opportunity to raise issues of serious concern for the hospital community - whether it's about implementing health care reform, protecting the resources needed to ensure access to quality care for all Illinoisans or ensuring the future sustainability of the health care system.”
To learn more, go to the IHA website.
The Leapfrog Group is an employer coalition that has developed a method of assessing hospital quality and patient safety in a range of important dimensions. The measures include objective data and self-reported compliance with safe practices. Participation is voluntary.
“The Leapfrog Group is a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded. Among other initiatives, Leapfrog works with its employer members to encourage transparency and easy access to health care information as well as rewards for hospitals that have a proven record of high quality care.
A range of hospital quality and safety practices are the focus of Leapfrog’s hospital ratings via the Leapfrog Hospital Quality and Safety Survey, as well as our hospital recognition and reward programs. Endorsed by the National Quality Forum (NQF), the practices are: computer physician order entry; evidence-based hospital referral; intensive care unit (ICU) staffing by physicians experienced in critical care medicine; and the Leapfrog Safe Practices Score.”
To learn more, go to the Leapfrog Group website.
NCDB: National Cancer Data Base (Commission on Cancer, American College of Surgeons)
The National Cancer Data Base includes information on care and survival for eleven common cancers. The comparison data are ©Commission on Cancer, American College of Surgeons. NCDB Benchmark Reports, v1.1. Chicago, IL, 2002.
“The National Cancer Data Base (NCDB), a joint program of the Commission on Cancer (CoC) and the American Cancer Society (ACS), is a nationwide oncology outcomes database for more than 1,400 Commission-approved cancer programs in the United States and Puerto Rico. … The content reproduced from the applications remains the full and exclusive copyrighted property of the American College of Surgeons. The American College of Surgeons is not responsible for any ancillary or derivative works based on the original Text, Tables, or Figures.”
To learn more, go to the NCDB website.
NDNQI: National Database of Nursing Quality Indicators
There are some patient quality and safety measures which have been shown through research to be significantly affected by nursing care or “nurse-sensitive” measures. These are collected through a combination of medical record review and administrative data, according to common definitions. The National Database of Nursing Quality Indicators is a leading voluntary system for collection and analysis of these data.
“The National Database of Nursing Quality Indicators® (NDNQI®) is a proprietary database of the American Nurses Association. The database collects and evaluates unit-specific nurse-sensitive data from hospitals in the United States.”
To learn more go to the NDNQI website.
NSQIP: National Surgical Quality Improvement Program
For selected surgical procedures, the voluntary American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) collects very detailed information based on clinical review of patient medical records according to common definitions.
“The ACS National Surgical Quality Improvement Program (ACS 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, which allows valid comparison of outcomes among all hospitals in the program.”
To learn more, go to the ACS NSQIP website.
Press Ganey Associates
Press Ganey Associates, Inc. is a national firm that provides services to survey healthcare consumers and patients about their experiences. Northwestern Memorial engages Press Ganey to survey our patients and to provide comparative data to enable us to identify opportunities to improve.
To learn more, go to the Press Ganey website.
SRTR: Scientific Registry of Transplant Recipients
All organ transplant centers must provide data on program performance and make the data available to transplant patients.
“The Scientific Registry of Transplant Recipients The Scientific Registry of Transplant Recipients is a national database of statistics related to solid organ transplantation - kidney, liver, pancreas, intestine, heart, and lung. The registry covers the full range of transplant activity, from organ donation and waiting list candidates to transplant recipients and survival statistics. Its purpose: to support the development of sound policy, to encourage research on issues of importance to the transplant community, and to facilitate responsible analysis of transplant programs and OPOs [Organ Procurement Organizations].”
To learn more, go to the SRTR website.
STS: Society of Thoracic Surgeons
The database of the Society of Thoracic Surgeons is a voluntary system which allows a hospital to contribute detailed clinical data collected from patient medical records according to common definitions in order to identify opportunities for improvement.
“The Society of Thoracic Surgeons offers outcome programs in the areas of Adult Cardiac, General Thoracic and Congenital surgery. By committing to collecting outcomes data to the STS National Database, surgeons are committing to improving the quality of care that their cardiothoracic surgery patients receive.”
To learn more, go to the STS website.
TJC: The Joint Commission
The Joint Commission is the organization that accredits Northwestern Memorial Hospital and thousands of other healthcare organizations. The Joint Commission has developed and adopted quality measures that hospitals voluntarily collect from patients’ medical records.
“An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 16,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.”
To learn more, go to The Joint Commission website.
UHC: University HealthSystem Consortium
This consortium of academic medical centers sponsors a database that contains administrative data from patient bills for hospital care. The database produces “observed” and “expected” mortality and other quality measures. These measures are considered less reliable than those which are based on intensive review of medical records, because the diagnosis and procedure data on bills are not very detailed. However, these measures are very easy and inexpensive to prepare, and they can be one part of an overall review of quality and safety.
“The University HealthSystem Consortium (UHC), Oak Brook, Illinois, formed in 1984, is an alliance of 103 academic medical centers and 219 of their affiliated hospitals representing approximately 90% of the nation's non-profit academic medical centers.”
To learn more, go to the UHC website.
Vermont Oxford Network
The Vermont Oxford Network (VON) is a voluntary collaboration to collect detailed clinical information about high-risk and very low birth weight infants in order to identify opportunities for improvement. The measures are collected by clinical review of medical records according to common definitions.
“Vermont Oxford Network (VON) is a non-profit voluntary collaboration of health care professionals dedicated to improving the quality and safety of medical care for newborn infants and their families. Established in 1988, the Network is today comprised of over 800 Neonatal Intensive Care Units around the world. In support of its mission, the Network maintains a Database including information about the care and outcomes of high-risk newborn infants. The Database provides unique, reliable and confidential data to participating units for use in quality management, process improvement, internal audit and peer review.”
To learn more, go to the Vermont Oxford website.