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CHRISTUS Health Quality Report
FAQs
- What is in this Quality Report?
- How were these measures selected?
- What effect do these indicators really have on the safety of your patients?
- Is this information available for hospitals that are not a part of CHRISTUS Health?
- Why is CHRISTUS Health publishing its data, if doing so is not required?
- If a hospital's performance is red, does that mean it provides bad care?
- How often is the data on this site updated?
1. What is in this Quality Report?
CHRISTUS Health displays clinical results (Our patient satisfaction and financial report are located in a separate section.)
Data
The data we display is in the form of numbers called "indicators," the percentage of patients who received care consistent with nationally recognized measures.Ratings
Ratings We rate our performance with indicators for each measure expressed in percentages. If national data are available for a measure, we compare our performance to the national average and color-code our results: green if we are better than the national average, red if we are worse than the national average and beige if we are near the national average. We use the latest data available from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to determine the national average, when available. (Note: The hospital numbers in a particular row are compared to the U.S. average in that row. A percentage in one row cannot be compared to a percentage in a different row.)It should be noted that in the charts broken down by facility, the number of procedures for each measure may vary widely. For instance, one of our hospitals may see only five heart failure cases in a given month, while another may see over 100. In each instance, however, the number of times a recommended procedure is performed or a recommended service is offered is divided by the number of possible candidates to receive that procedure. Only patients meeting the inclusion criteria for a measure are included in the calculation of the rate for a measure. For example, both the Centers for Medicare & Medicaid Services and JCAHO recommend that every heart failure patient receive detailed discharge instructions on how to manage their condition in the future. If only 4 out of 5 heart failure patients receive these instructions in a given month, then that would mean that the hospital provided the recommended process 80 percent of the time. The goal for each measure is 100 percent.
Pop-ups
Throughout the report, links and "pop-up" boxes may be activated by pointing and clicking with your mouse. For example, you can click on a measure’s description or number, and a temporary box will open that provides additional explanation.
2. How were these measures selected?
National quality organizations have endorsed lists of quality measures and indicators. In this report, we include the measures that Centers for Medicare & Medicaid Services (CMS) require that we report to them. We also considered the requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), although we don’t report on all of the National Quality Improvement Goals set by JCAHO. For more on these organizations, please visit their websites.
3. What effect do these indicators really have on the safety of your patients?
It has been proven that the simplest treatments can reduce risk. According to the American Heart Association, Medicare and the Department of Veterans Affairs, these measures have the following impact:
| Condition |
Treatment |
Reduced Risk |
|---|---|---|
Heart Attack |
Patient given aspirin upon arrival at the hospital |
23% less chance of dying within the next 35 days |
Heart Attack |
Heart attack Patient continues to take aspirin after leaving the hospital |
25% less chance of having another heart problem or a heart-related death |
Heart Attack |
Given a beta blocker upon arrival at the hospital |
14% less chance of dying within one week |
Heart Attack |
Prescribed a beta blocker when they leave the hospital |
28% less chance of having another heart attack |
Heart Attack |
Prescribed an ACE inhibitor before leaving the hospital |
27% less chance of having another heart attack |
Heart Failure |
Prescribed an ACE inhibitor before leaving the hospital |
20% less chance of dying within one year |
Pneumonia |
Patient gets a pneumonia vaccine before leaving the hospital |
43% less chance of being hospitalized and 29% less chance of dying from pneumonia or influenza |
The hospital quality measures on this website show recommended care for some of the most common and costly conditions that hospitals treat. Research has shown that these treatments provide the best results for most adults with those conditions and are an important part of patients' overall care.
Hospitals, doctors, scientists, and other health care professionals agree that these quality measures give a good snapshot of how well hospitals provide these specific types of care. Hospitals should try to give all of their patients the recommended care when it is appropriate. The goal for each measure is 100 percent.
4. Is this information available for hospitals that are not a part of CHRISTUS Health?
Not usually. Most of the clinical information displayed here is not currently publicized by other hospitals. Data for many of these measures can be found at Hospital Compare. CHRISTUS Health voluntarily posts the majority of the data requested on that site, but the information we display in this report is more comprehensive and current.
5. Why is CHRISTUS Health publishing its data, if doing so is not required?
At CHRISTUS Health, we believe it is critical to our ministry that we carefully monitor our quality data so that we can further our mission of extending the healing ministry of Jesus Christ. We feel strongly about fostering a culture of transparency, and reporting this data so that you know how we are performing aids us in creating such a culture. This transparency ensures that our patients, their families and our Associates and physicians can hold each other accountable to the high standards of compassion and excellence that we have set for ourselves.
6. If a hospital's performance is red, does that mean it provides bad care?
It's not that simple.
There are many possible reasons that performance on an indicator might be red. (Turn these around to consider reasons that performance on an indicator might be green.) Here are a few:
- The hospital may provide care that is below than the national average.
No one wants to be below than average, but even performance that is significantly lower than the national average may still be well within the range of good care. - The indicator may do a poor job of capturing what it's trying to measure.
Indicators that are especially likely to be weak in this regard include those based only on number of procedures and those based on billing data. - The percentage calculated may come from a very small pool of patients. If a hospital only has two cases of one indicator and fails to perform that procedure or service on one, that could lead to a 50 percent performance rating, which is almost always below the national average.
7. How often will the data on this report be updated?
This report will be updated quarterly.
