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What is the Quality Report?

This Quality Report Card provides an at-a-glance view of key indicators that Northwest Community Hospital uses to evaluate our performance in terms of patient care (clinical quality), nursing care, patient satisfaction and patient safety. It’s an attempt to quantify our level of performance using measurable factors.

Why make our Report Card so public?

We’ve got nothing to hide. We believe it’s important for health consumers to be fully informed about a hospital’s performance, so they can feel confident about the healthcare provider they choose.

The Report Card is one way to keep Northwest Community Hospital accountable to the people it serves. This Report Card presents our quality performance data in a format that is “transparent” (easy to see) for all healthcare consumers.

Why are these specific factors and practices being measured? Why not others?

The factors reported here relate to common reasons that draw people to hospitals. They’re also the measures that many state, national and independent organizations choose to monitor and report.

Using measures that are consistent with other organizations helps the public to objectively compare scores between multiple hospitals across their area, their state and the nation. It provides an easy-to-decipher look at each hospital’s performance across a spectrum of clinical and support services.

A word of caution: Although most hospitals and organizations report on many of the same measures, their methods of analyzing and reporting the data can be slightly different. This can sometimes make it hard to compare directly between different healthcare organizations.

What does “evidence-based practice” mean? What are “best practices”?

Evidence-based practices and best practices are interrelated. These are practices which have been shown to deliver the best results for most patients, based on studies of patient outcomes. Practices that are proven by evidence to deliver these optimal results usually become accepted throughout the healthcare industry as a “best practice.”

For example, giving patients an antibiotic within one hour before surgery has been shown by evidence to reduce their risk of developing infections related to the surgery. This practice is now accepted industry-wide as an evidence-based practice or best practice.

Why are some scores in the red? Does that mean the hospital provides bad care?

Let’s face it. Even the very best hospitals sometimes have scores that are below average for specific indicators. If that happens at Northwest Community Hospital, we’re not going to hide the truth. That’s what we mean by being transparent: you can see areas where we exceed averages and areas where we might fall behind.

For us, any score that falls below expectations is not something to hide… it’s something to focus on. We must continuously be aware of our weaknesses as well as our strengths. Through quality improvement initiatives, we aim to bring all lower scores up to the highest standards.

Does this Quality Report Card display data about specific physicians?

No, the Quality Report Card does not display data about any specific physicians. Instead of focusing on individuals, the report provides an overview of the quality of care provided at Northwest Community Hospital, based on defined measures for performance.

Is this information available for hospitals other than Northwest Community Hospital?

Yes and no. Many hospitals across the U.S. are keeping data on quality performance measures and reporting their data to government agencies or industry watchdogs like the Leapfrog Group. Selected information from these data reports is available to the public online.

However, only a small percentage of hospitals nationwide have taken the lead in making their quality data easily available to the public. Northwest Community Hospital is among the leaders who have posted their “report cards” online for all to see.

How can I use this information?

You can use this data to compare the performance of Northwest Community Hospital with averages for hospitals in Illinois or across the U.S., based on specific indicators. The quality measures included here are the same ones being used by the federal government and healthcare organizations to help quantify or “measure” the performance of the nation’s hospitals.

Why are the details so important?

Sometimes, the difference is in the details. Think about it. Many hospitals treat heart attacks. But, how do they compare on the small details that may make a big difference in the patient’s experience at that hospital?

For example, how often does the hospital give heart attack patients aspirin within 24 hours of their arrival? (Aspirin reduces blood clotting and has been shown to improve a person’s chance for surviving a heart attack. Giving aspirin within 24 hours of arrival to heart attack patients is considered an “evidence-based practice” in the healthcare field.)

The aspirin example illustrates the types of performance details you can find on this website.

What are the drawbacks of quality reporting?

For one thing, quality reporting can be overwhelming and even confusing. With different agencies reporting on different data, healthcare consumers confront great variation within the information that’s available.

Another concern is that different hospitals may use slightly different methods to collect and report their data. So, you may not be able to exactly compare one hospital’s scores with scores from another hospital. Nonetheless, the quality scores can give you a general idea of the hospital’s level of commitment to quality performance.

How often will this Quality Report Card be updated?

We intend to keep the data on this Report Card as up to date as possible. So, as soon as we collect and process new data for a given measure, we will post it online. Some measures are analyzed every month, so you can expect updated data monthly. Other measures, including the Hospital-Consumer Assessment of Health Providers and Systems (H-CAHPS) and Press Ganey patient satisfaction data, are reported on a quarterly basis.

There are some measures that cover areas where fewer patients are affected, so it takes us longer to measure results for enough patients to make the data valid. These types of measures will be updated as we collect and analyze sufficient new data.

How does Northwest Community Hospital use this performance data?

Northwest Community Hospital continually measures its performance on many different factors that affect patients’ experience and quality of care. We use this data to know where we are meeting standards, and where we can take steps to do better for our patients.

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Last Updated 01/29/2010