Quality at the Nassau University Medical Center

About the Reports

1. What is in this report?

NuHealth is displaying hospital-specific performance data on Acute Myocardial Infarction, Pneumonia, Heart Failure, Surgical Care Improvement, Hospital Acquired Infections, Stroke, Nursing Quality and Patient Satisfaction.

Data Quality Indicators
NuHealth looks at two types of indicators. Process indicators measure the completion of steps in the process (for example, antibiotic delivery within 1 hour of surgical incision). Outcome indicators measure the result of the process such as mortality and infection rates. 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. The average used, national or state, will be clearly indicated on each report.

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.

Hospitals are required to collect and submit core measure data to the Center for Medicare & Medicaid Services (CMS). Core measures track a variety of evidence-based, scientifically researched standards of care that have been shown to result in improved clinical outcomes for patients. Nu Health submits core measure data for 4 categories (acute myocardial infarction, community-acquired pneumonia, congestive heart failure, and surgical care improvement project). Under each category, key actions are listed that represent the most widely accepted, research-based care process for appropriate care in that category.

These findings are publicaly reported by:

The Department of Health’s New York State Hospital Profile

The U.S. Health and Human Services on Hospital Compare

Nu Health participates in the patient satisfaction survey HCAHPS, which stands for Hospital Consumer Assessment of Healthcare Providers and Systems. It was developed by the Centers for Medicare and Medicaid Services (CMS) to measure patient perceptions of care. This survey asks questions that are standardized for all hospitals across the United States. The information is reported to a government-sponsored web site.

Public Health Law 2819 requires hospitals to report select hospital-acquired infections (HAIs) to the New York State Department of Health. This law was created to provide the public with fair, accurate and reliable hospital-acquired infection (HAI) data to compare hospital infection rates, and to support quality improvement and infection-control activities in hospitals.

Nu Health participates in “Get with the Guidelines” (GWTG). GWTG is an evidence-based program for in-hospital quality improvement. It puts the expertise of the American Heart Association and American Stroke Association to work for hospitals, helping to ensure that the care they provide to heart failure and stroke patients is aligned with the latest scientific guidelines.

NuHealth participates in the National Database of Nursing Quality Indicators (NDNQI)

NDNQI is national nursing database that provides quarterly reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level.

Additional web sites that provide public reporting of hospital quality measures:


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

If our hospital 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 that an indicator may be red and a hospital may still be providing good care. Some of those reasons are:

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

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 hospital 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. What are some of the Quality Initiatives that we participate in?

Organizations invite hospitals to participate in focused quality initiatives. By participating, hospitals agree to adopt evidence-based practices and share their outcomes.

NuHealth actively participates in:

New York State Partnership for Patients (NYSPFP)  – A partnership for improving quality of care and patient safety. The aim of the initiative is to reduce hospital-acquired conditions by 40%, and readmissions by 20%. The focus is on engaging the front line staff to drive improvement and sustain reliable best practices.

TeamSTEPPS – An evidence-based teamwork system to improve communication and teamwork skills among health care professionals and improve patient safety.

7. 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.