Quality Measures for LLUMC

In 2001, the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) launched Quality Initiatives to assure quality health care for all Americans through accountability and public disclosure. This effort was supported by the adoption of quality measures. A quality measure is medical information from patient records converted into a rate or percentage that shows how well hospitals care for their patients in certain categories. Each measure is an evidence-based, scientifically-researched standard of care which has been shown to result in improved clinical outcomes. The development of each quality measure topic is based on the following criteria:

• High impact disease (cost, morbidity, mortality, quality of life)
• Guidelines that provide best practices that can be measured
• Gaps in care (opportunities for improvement)

This data is collected and submitted by LLUMC through MIDAS, a third-party vendor authorized to do so on our behalf. Utilizing the data abstraction guidelines provided in the Specifications Manual, hospitals abstract medical record data for each quality measure to report our performance.

Hospital Compare is the website tool developed to publicly report user-friendly information (measures) about the quality of care delivered in the nation’s hospitals. We, at LLUMC, are committed to participate in this program by maintaining data integrity and utilizing this information to improve patient care.

Every Patient Every Time