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Quality Measures

At Pomona Valley Hospital Medical Center (PVHMC) our expert providers and caregivers are committed to providing safe, high-quality medical care to all patients.

As part of this commitment, PVHMC participates in a number of quality reporting efforts by various organization. Quality measures are often used to determine the performance of hospitals, health professionals and physicians. In collaboration with the Hospital Quality Institute (HQI), the California Hospital Association (CHA), we are providing this information in an effort to help you make an informed decision about your healthcare services.

The data provided below represents care provided to inpatient beneficiaries only and will be updated on a regular basis. (Information is based on the most current data available).

Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate (NTSV)

NTSV

NTSV rate is the percentage of cesarean (surgical) births among first-time mothers who are at least 37 weeks pregnant with one baby in a head down position (not breech or transverse). Lower values indicate that fewer cesareans were performed in the hospital among primarily low risk, first-time mothers. Lower values are better.

Limitations: NTSV rates do not take into account certain obstetric conditions, such as placenta previa, that may make Cesarean delivery the safer route for both mother and infant.

*Data were retrieved from CMQCC (California Maternal Quality Care Collaborative).

Pomona Valley Hospital Medical Center has a Maternity Safety Program in place. A maternity safety program provides a coordinated approach and emergency response to risks associated with pregnancy and childbirth.

Venous thromboembolism (VTE)

VTE

VTE is the measure of patients who develop deep vein clots who had not received potentially preventive treatment. Lower values are better.

Limitations: Although not adjusted to account for patient-specific risk factors, this rate is helpful in distinguishing a hospital’s adherence to the best practice of administration of appropriate VTE prophylaxis to all appropriate patients.

*Data were retrieved from CMS Hospital Compare Timeliness & Effectiveness of Care files, which are updated quarterly in April, July, October, and December.

Pomona Valley Hospital Medical Center has a Respiratory Monitoring program in place. Respiratory monitoring provides guidance for the assessment of the risk of respiratory depression and includes continuous monitoring of breathing and functioning of the lungs and circulatory system when indicated.

Central Line-Associated Blood Stream Infection (CLABSI)

CLABSI

CLABSI is a serious infection that occurs when germs enter the bloodstream through a central line. A central line is a special intravenous catheter (IV) that allows access to a major vein close to the heart and can stay in place for weeks or months. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measured period. SIRs below 1.00 indicate that the observed number of infections during the measured period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Lower values are better.

Limitations: In the calculation of the Standardized Infection Ratio (SIR), the CDC adjusts for differences between hospitals. However, patient risk factors are not taken into account. These patient-specific variables (e.g., poor skin integrity, immunosuppression) can increase the risk of developing a central line infection. Hence, the SIR for hospitals that care for more medically complex or immunosuppressed patients may not be adequately adjusted to account for those patient-specific risk factors.

*Data were retrieved from CMS Hospital Compare HAI files, which are updated quarterly in April, July, October, and December.

Colon Surgical Site Infection (SSI)

ColonSSI

Colon SSI is an infection (usually bacteria) that occurs after a person has colorectal surgery that occurs at the body site where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, organs, or implanted material. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measured period. SIRs below 1.00 indicate that the observed number of infections during the measured period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Lower values are better.

Limitations: Some, but not all patient-specific risk factors are included in the adjustment of the SIR for these types of infections. However, not all relevant risk factors are included (e.g., trauma, emergency procedures). Hence, the SIRs for hospitals performing more complex procedures or with larger volumes of trauma or emergency procedures may not be adequately adjusted to account for those patient-specific risk factors.

*Data were retrieved from CMS Hospital Compare HAI files, which are updated quarterly in April, July, October, and December.

Sepsis Mortality

SepsisMortality

Sepsis Mortality is the percent of patients, with a severe infection, who die in the hospital. Most sepsis cases (over 90%) start outside the hospital. A lower percentage of death indicates better survival. Lower values are better.

Limitations: Use of discharge/administrative data is limiting since such data has lower specificity for diagnoses than clinical data. In addition, without risk adjustment for differences in patient-specific factors, comparing rates among hospitals is difficult.

*Data are based on the OSHPD Inpatient AB2876 Discharge File, which is updated annually around August.

Pomona Valley Hospital Medical Center has a Sepsis Protocol in place. A sepsis protocol provides guidance for a coordinated approach to identification and treatment of an infection and inflammatory response which is present throughout the body.

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