Quality and Patient Safety

Mortality

What the measure means: The mortality rate looks at how many patients die in the hospital compared with the expectation of continued survival, which depends on how severe their conditions are.  

BMC Performance: 

*Source: Center for Medicare and Medicaid Services/Hospital Compare

What we are doing to improve:

• Reviewing all mortality cases to ensure high quality care was given.
• Improving the timeliness of early recognition and treatment of sepsis, both when present on admission and when it develops after admission. 
• Review overall mortality data to identify areas of focus and potential opportunity to improve care delivery.

Readmissions

What the measure means: Our goal is that once a patient is discharged from a hospital stay, they will have a plan of care and any needed outpatient services that will help ensure they will not need to return to the hospital within a month for an unplanned visit. This measure looks at how many patients do need to return for a second inpatient stay within 30 days.

BMC Performance:

What we are doing to improve:

• Ensuring timely outpatient contact with providers for patients with conditions that make them more likely to have to return to the hospital.
• Discharging patients with easy-to-understand instructions, using their preferred language, pictures, charts, etc.
• Arranging outpatient care and services to meet patient needs in their community.

Hand Hygiene

What the measure means: Proper hand hygiene is a necessary action to help stop the spread of germs. Staff and providers conduct weekly observations of hand hygiene across the hospital to identify performance.

BMC Performance:

What we are doing to improve:

• Hand sanitizer is located inside and outside patient rooms for easy access for staff and visitors. Dispensers are routinely monitored to make sure they are filled and working.
• Sinks are located inside or close to patient rooms for times when soap and water handwashing is required. Soap dispensers are routinely monitored to make sure they are filled and working.
• If needed, staff are encouraged to remind each other to complete hand hygiene.
• Patients and visitors are encouraged to ask staff and providers if they have used hand hygiene.
• Staff and providers receive regular education on proper hand hygiene techniques.
• For specific hand hygiene needs, signs are posted on patient doorways.
• All units receive regular reports of their performance. Leadership immediately acts on any identified gaps in compliance.

Hospital Acquired Infections

What the measures mean: When patients are sick, they may need to have devices, such as urinary catheters or central venous lines to help them get better. These devices have some risks, such as infection. While infections are largely preventable, they may happen in some complex patient situations, despite meticulous care and treatment.  

Likewise, other treatment to help patients return to health, such as antibiotics, also have some associated risks. For example, Clostridioides difficile (C-diff) is a type of bacteria that may be associated with antibiotic use. 

BMC Performance:

*Infections are reported using a standardized infection ratio (SIR). The SIR compares the actual number of infections at a hospital to a national benchmark based on data reported to the National Healthcare Safety Network (NHSN).

What we are doing to improve:

• Ensuring high compliance with proper hand-washing, before and after patient care.
• Making every attempt to not use these devices whenever possible and if needed, remove them as soon as possible.
• Always using the best possible technique to put devices in.
• Consistent use of best possible care for maintaining devices.
• Learning from each situation in which an infection occurs to continually improve our system of care.
• Careful attention to ensuring best practices for antibiotic stewardship.

Patient Safety Indicators (PSI-90)

What the measures mean: PSI-90 is a group of measures that relate to a set of potentially preventable events that are associated with harmful outcomes for patients, such as pressure injuries, in-hospital falls with hip fracture, post-operative sepsis, respiratory problems, kidney injury and wound separation, peri-operative blood clots or bleeding.

What we are doing to improve: Using several best practices for prevention of the complications in the PSI-90 measure group, BMC provides care that will help patients avoid these harms. For example, to prevent blood clots in the lung or large veins after surgery, patient risk levels are identified and medicine may be given for prevention.

Perinatal Care

Doctors and hospitals can improve chances for a safe delivery and a healthy baby by providing care that will promote optimal outcomes. 

What the measure means: Early elective delivery is defined as delivery by induction of labor without medical necessity followed by vaginal or caesarean section delivery or a delivery by caesarean section before 39 weeks gestation without medical necessity.

BMC Performance:

What we are doing to improve: Interventions are in place to only perform induction of labor and caesarean delivery at the optimal time for safe care, unless medically necessary to perform earlier.

Healthcare Personnel Influenza Vaccination

Flu is a contagious disease that spreads around the United States every year, usually between October and May. While anyone can get the flu, but it is more dangerous for some people than others. Each year, thousands of people in the US die from the flu and many are hospitalized. Flu vaccine prevents millions of illnesses and flu-related visits to the doctor every year.

Healthcare staff and providers promote preventative behavior through role modeling and by providing education about preventative services.

BMC Performance:

What we are doing to improve: 

• Every year in October, Influenza vaccine is readily available to staff and providers. 
• Adherence data is consistently monitored and staff are personally engaged for compliance.

Center for Medicare and Medicaid Services

BMC is certified as a Medicare and Medicaid hospital provider. The Massachusetts Department of Public Health carries out certification surveys on behalf of CMS.

The Joint Commission

BMC is accredited by The Joint Commission’s Hospital Accreditation Program, an independent nonprofit organization that evaluates healthcare organizations on specific quality and patient safety standards.

Comprehensive Stroke Certification (CSC) Joint Commission

BMC is recognized as a hospital that has the specific services, resources, staff expertise, and training required to treat complex stroke.

Commission on Cancer

BMC’s Cancer Center is accredited by the American College of Surgeons Commission on Cancer. Accreditation recognizes the Cancer Center’s commitment to comprehensive and patient-centered care, a multidisciplinary approach, clinical trial access, lifelong patient follow-up, psycho-social support, and continuous quality improvement.

Massachusetts Department of Public Health (MDPH)

BMC complies with all regulations under Massachusetts general law related to hospital licensure and healthcare facility reporting, including the reporting of serious reportable events (SREs).