Graphic illustration of different types of data analysis.

Clinical Quality

Main Content

Our Quality Measures

Hand Hygiene and Hospital-Acquired Infections

A robust hand hygiene program (HH) is the major driver for eliminating hospital-acquired infections (HAI). HAIs include infections related to central lines and urinary catheters, Clostridium difficile, and surgical site infections. UMMC made reduction of HAIs a primary quality improvement goal, and as shown in the graphic (access the graph in the link below) these have fallen by over 60% in the past four years. The sustained improvement in HH in this graph, combined with standardizing other infection prevention practices are the mainstays of this program as we drive to achieve zero HAIs. Of note, the COVID pandemic created instability in HAI rates in 2020 and 2021.

Reportable Complications

Reportable Complications provide information on potentially avoidable complications that may represent opportunities for improvement in the delivery of care. Reportable Complications trends are monitored closely and multidisciplinary teams are formed to develop evidence based strategies to prevent and manage these complications. Over the past five years, UMMC has experienced a significant reduction in Reportable Complications resulting in a 33% improvement in the number of Reportable Complications per month. 

Patient Experience

All hospitals are required to survey their discharged patients using a national standardized survey administered by independent vendors. There are 10 domains to the hospital survey primarily around communication with patients and family. The data are published on Hospital Compare and used in both reputation and pay-for-performance programs. UMMC scorecard reports the overall hospital rating by patients as our main patient experience measure: this has steadily increased over the past 5 years and is now better than half all hospitals in the USA.