Quality at A. Holly Paterson

About the Reports

1. What is in this report?

NuHealth is displaying our extended care facility specific performance data on prevalence of falls, skin care, restraints, mental health, bowel/bladder management, physical activity, vaccination and pain management.

Data Quality Indicators:
NuHealth looks at two types of indicators. Process indicators which measure the completion of steps in the process for example; flu and pneumonia vaccinations. Outcome indicators measure the result of the process such as preventing pressure ulcers. Clinical outcomes are numbers calculated to represent our performance for a quality indicator.

We rate our performance for a quality indicator as a percentage. Our performance is compared to either a national or state average and then color coded as follows: green indicates at or better than the national or state average, yellow near the national or state average and red indicates room for improvement.

Additional Information
Throughout the report additional information is available by clicking on the link highlighted in blue.

2. Where did these quality indicators come from?

Quality Indicators are developed from the recommendations of professional societies and research studies.

Extended Care Facilities are required to collect and submit data to the Center for Medicare & Medicaid Services (CMS).

These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare http://www.medicare.gov

3. How did we determine a value for each color-code?

If our extended care facility performed at or above the national or state average we color-code our performance as green. Performance 10% or less below the national or state benchmark is color-coded yellow. Red indicates performance greater than 10% below the national or state average.

4. If the performance for an indicator is red, does that mean the hospital provided bad care?

Unfortunately, this question cannot be answered with a simple yes or no. Many components go into this and there are a variety of reasons why an indicator may be red and a hospital may still be providing good care. Some of those reasons are:

The extended care facility may do a better job of detecting and reporting complications and/or infections than other extended care facilities – this would make it seem that the extended care facility’s outcomes are worse, when, in reality, that extended care facility is just doing a better job of reporting than other extended care facilities.

The indicator may do a poor job of capturing what it is trying to measure.

The indicator’s risk adjustment statistical model may not take into account all of the factors that it should. This could result in the extended care facility not getting full credit for the complexity of its cases.

NuHealth encourages you to discuss any issues you have regarding our outcomes with your healthcare provider.

5. How often will the data in this report be updated?

Reports will be updated on a quarterly basis and will represent an average of the most current 12 months of available data.

6. How can I contact NuHealth if I have any questions regarding the Quality Reports?

You can contact us at qualityanswers@numc.edu. All questions will be promptly answered by a member of NuHealth’s Quality Management team.