Quality Improvement Measures

CMS (Center for Medicare & Medicaid Services) provides an array of information on hospitals for patient research, including comparisons of a hospital's performance against state and national averages. To view Covenant HealthCare's information, please visit the CMS Hospital Compare website. Additional hospital comparison information can be found at the MHA Keystone Center.

The following is a brief description for each of the tabs from the CMS Hospital Compare link above:

  • General Information: Basic information from hospitals such as contact information and hospital type
  • Survey of Patient’s Experiences: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national survey that asks patients about their experiences during a recent hospital stay with the results showing 11 important quality topics
  • Timely & Effective Care: Shows how often hospitals provide care that research shows gets the best results for patients with certain conditions
  • Readmissions, Complications, & Deaths: Shows how often patients admitted to the hospital for treatment of medical problems face other serious injuries, complications, or conditions, and death
  • Use of Medical Imaging: Provides information about hospitals' use of medical imaging tests (like Mammograms, MRIs, CT scans) for outpatients
  • Payment & Value of Care: This looks at how much Medicare spends at the hospital, while also looking at patient outcomes and payment measures together to allow patients and caregivers to assess the value of care a hospital provides
  • Number of Medicare Patients: This shows the number of Medicare patients with a certain condition (MS-DRG) that a hospital treated during the current data collection period

In addition, 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. CMS established the Core Measures in 2000 and began publicly reporting data relating to the Core Measures in 2003.

There are several Core Measure categories (Acute Myocardial Infection, Community Acquired Pneumonia, Congestive Heart Failure, and Surgical Care Improvement Project, Stroke, VTE, Global, and OP). Under each category, key actions are listed that represent the most widely accepted, research-based care process for appropriate care in that category.

It is important to note that these care recommendations are subject to the professional medical advice of each patient’s physician and the particular health conditions of each patient. If a physician determines that a patient is not an appropriate candidate for a particular care process, the physician can document the contraindications to that care process and the patient will not be included in the data.

The following are some of our focus measures:

  • AMI: An acute myocardial infarction (AMI), or heart attack, happens when one of the heart’s arteries becomes blocked and the supply of blood and oxygen to part of the heart muscle is slowed or stopped. These measures show some of recommended treatments provided, if appropriate, for most adults who have had a heart attack.
  • CHF: Congestive Heart Failure (CHF) is a weakening of the heart's pumping power and with heart failure, your body doesn't get enough oxygen and nutrients to meet its needs. These measures show some of the recommended treatments provided for most adults with heart failure.
  • PN: Pneumonia (PN) is a serious lung infection that causes difficulty breathing, fever, cough and fatigue. These measures show some of the recommended treatments for pneumonia.
  • SCIP: Surgical Care Improvement Project (SCIP) focuses on reducing the risk of infection after surgery by making sure they provide care that’s known to get the best results for most patients. These measures show timely and effective care received by the patients.
  • ED Care: Emergency Department (ED) Care is the timely and effective care received by patient who have serious illness or injuries that need to be attended to immediately. The measures show how quickly Covenant HealthCare treats patients who come to the emergency department.
  • Preventative Care: Promoting, providing and educating patients about services, screenings and maintaining health of the community. These measures show how well Covenant HealthCare is providing preventive services.
  • Stroke Care: Sometimes referred to as a "brain attack," a stroke occurs when blood flow to the brain is interrupted. When a stroke occurs, brain cells in the immediate area begin to die because they stop getting the oxygen and nutrients they need to function. These measures show some of the standards of stroke care that hospitals should follow, for adults who have had a stroke.
  • Blood Clot Prevention & Treatment: Blood clots are clumps that occur when blood hardens from a liquid to a solid. These measures show how well hospitals are providing recommended care known to prevent or treat blood clots and how often blood clots occur that could have been prevented.
  • Pregnancy & Delivery Care: By providing care to pregnant women that follows best practices, hospitals and doctors can improve chances for a safe delivery and a healthy baby. This measure shows the percentage of pregnant women who had elective deliveries 1-3 weeks early (either vaginally or by C-section) whose early deliveries were not medically necessary.