What is quality of care and how is it measured? This is the million dollar question that patients, doctors, and healthcare administrators have been trying to answer. It is our mission at UT Health Northeast to provide our patients with the highest quality and safest care possible. Therefore, we want you to see how we are performing with many of the most important metrics for our hospital.
Below, you will find a list of topics that we find extremely important. Click on a category to learn about that measure and and how we are performing.
Patient Experience: Overall Hospital Rating (HCAHPS)At UT Health Northeast we are committed to providing the highest quality and most compassionate care to our patients. From the first point of contact, to addressing our patient’s healthcare needs following discharge, our employees are committed to making our patient’s experience the best that it can be. Our ultimate goal is to provide patient-centered care, which has six core attributes:
- Education and shared knowledge
- Involvement of family and friends
- Collaboration and team management
- Sensitivity to non-medical and spiritual dimensions of care
- Respect for patient needs and preferences
- Free flow and accessibility of information
We utilize HCAHPS survey data to measure our performance and insure that we are meeting our patient’s needs. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a patient satisfaction survey required by The Centers for Medicare and Medicaid Services (CMS) for all hospitals in the United States. The intent of the HCAHPS initiative is to provide a standardized survey that measures patients’ perspectives (opinions) on the hospital care they received.
The HCAHPS survey contains 21 patient perspectives on hospital care within nine key topics:
- Communication with doctors
- Communication with nurses
- Responsiveness of hospital staff
- Pain management
- Communication about medicines
- Discharge information
- Cleanliness of the hospital environment
- Quietness of the hospital environment
- Transition of care
These survey results are publicly reported by CMS and are available so that patients can see the quality of services offered by Hospitals in their area and compare them to other hospitals throughout the nation.
Our HCAHPS survey results represent the voice of our patients. We use these results to focus our improvement efforts for patient satisfaction. We want to empower our patients to make informed decisions about their care; therefore we provide them needed information and involve them in the decision making process for their care. The HCAHPS Survey evaluates things like:
- How often physicians explain things in a way you could understand
- How often you got help as soon as you wanted it
- How often nurses treated you with courtesy and respect
- Cleanliness of the hospital
- Whether you will have the help you need when you leave the hospital
All of these categories are scored and provide and overall rating for the hospital.
note: July break in trend resulted from the acquisition of our survey vendor by another.
As part of our ongoing campaign to provide patient centered care, and achieve institutional excellence, UT Health Northeast has implemented a Patient Family Partnership Committee. The partnership committee is a team made up of hospital staff and previous &/or present patients. Patients who participate in this Committee feel engaged in their care and are eager to work in collaboration with us to improve every patient’s overall experience at UT Health Northeast. The patient’s experience and well being are the foundation for our improvement efforts.
Catheter Associated Urinary Tract InfectionsA Catheter Associated Urinary Tract Infection (CAUTI) is an infection caused by the presence of a urinary catheter in the bladder. CAUTIs are the most common type of hospital acquired infection. They can cause great discomfort, and longer hospital stays.
The UT Health Northeast strategy for CAUTI prevention is simple:
- Educate patients and clinicians regarding associated risks, proper insertion, and care of urinary catheters
- Use them only when necessary
- Remove them as soon as possibl
Patients can help prevent CAUTI by asking care providers 1.) if they have washed their hands before and after care 2.) if the urinary catheter is medically necessary, and by avoiding crimped catheter tubing and backflow of urine from the tubing to the bladder.
Central Line Associated Blood Stream InfectionsA Central Line Associated Blood Stream Infection (CLABSI) is a serious, sometimes fatal, but preventable infection caused by the introduction of bacteria into a patient’s bloodstream through the insertion site of a central line. A central line, or central venous catheter, is a tube placed in a large vein close to the heart through an access point in the neck, chest, or groin. It is used to give patients medications or fluids and to collect blood for medical tests.
CLABSI prevention is a UT Health Northeast top priority. Only specially trained clinicians are authorized to insert central lines, following a strict protocol that includes the use of a checklist to ensure all necessary steps in the process are performed. Before receiving a central line, you should be educated about the risks associated with a central line before insertion.
It is important for patients and family members to participate in this process by asking questions such as:
- Is a central line necessary for my treatment?
- How soon can my central line be removed?
Avoid touching the line as much as possible. Visitors should wash their hands when they arrive and should avoid touching the line. Clinicians should perform hand hygiene using alcohol rub or soap and water before and after providing care. The insertion site (where the needle and tube enter the skin) of the central line should always remain clean and dry.
Hand HygieneProper hand hygiene is the most important step to prevent infection and the spread of disease. At UT Health Northeast we routinely monitor hand hygiene compliance through the use of “secret observers.” Secret observers monitor compliance with hand hygiene:
- Upon entry and exit from a patient’s room
- Prior to patient contact
- After removing gloves
- Before an invasive procedure
- Before and after touching (with gloved hands) a soiled dressing or a wound
There are 2 ways to perform hand hygiene: 1) wash hands with soap and water, rubbing hands together to create friction for at least 20 seconds before rinsing 2) use an alcohol-based hand sanitizer, rubbing hands together for at least 20 seconds.
Direct care staff is required to keep fingernails short and well groomed; they may not wear artificial nails or colored polish when providing care.
As the most important member of this healthcare team, patients are encouraged to ask clinicians if they have washed their hands. Protect yourself and others by speaking up when you see that visitors and clinicians do not comply with good hand hygiene!
Reduce Serious Safety EventsA serious safety event is an unanticipated adverse event that is not part of the natural course of the patient’s disease and results in serious harm to the patient or has the potential to result in serious harm.
UT Health Northeast seeks to provide perfect care to our patients. When a serious safety event does occur, we systematically review the event to identify ways to prevent it from happening again. Proactively, staff report “good catches” or potential problems that have not reached a patient but could if not addressed. These good catches provide the opportunity to systematically review safety conditions and correct problems before they reach our patients.
Patients can assist in preventing safety events by speaking up about concerns, being aware of their medications and treatments, and asking questions of their healthcare providers. Trust your instincts! If something doesn’t feel right, we encourage you to speak up! Learn about the questions to ask your doctor.
Surgical Site InfectionsA Surgical Site Infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical Site Infections are the second leading cause of healthcare associated infections (HAIs) nationwide. These infections can range from minor irritations at the incision site to severe wound infections that require intensive antibiotic treatment and further surgery.
UT Health Northeast uses evidence-based prevention methods to prevent SSI, such as:
- Choosing the least invasive treatment option possible
- Screening for risk factors that contribute to infection risk (tobacco use, diabetes, etc.)
- Pre-surgery testing for common bacteria that cause infections
- Using Preventive antibiotics when appropriate
- Preparing the surgical site according to strict standards
- Preventing contamination of the surgical site during the procedure
- Using strict hand hygiene standards
It is important that you follow your surgeon’s pre- and post-surgery instructions exactly. Ask questions when instructions aren’t clear and never allow anyone to touch your surgical wound or bandage with unwashed, ungloved hands.
Quality CareThe goal of the University of Texas Health Northeast is to deliver excellent care to our patients, following evidence-based practices. By using the best treatments available we improve patient outcomes by reducing returns to the hospital and deaths. We can see how well we’re meeting our goals by measuring compliance with best practices for several common diseases and care processes.
Our focus is to be the best facility for providing quality inpatient and outpatient care and achieving excellent outcomes:
Hospital Quality Care
Emergency Department Care
These metrics represent the average times our patients are spending in our Emergency Department – either for seeing a provider or for the entire emergency department visit.
Sepsis is the body’s overwhelming and life threatening response to infection, which can lead to tissue damage, organ failure and death. Nationwide almost one in two patients with severe forms of sepsis like septic shock can die. Sepsis occurs when the body’s own defenses overreact to an infection. This can lead to effects that block blood flow to organs, resulting in the patient’s death.
On October 1, 2015, the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) launched a Sepsis Core Measure for all 4000 Joint Commission-accredited U.S. hospitals.
In our facility we have teams trained in early diagnosis, testing and treatment, so that our patients can have lower rates of complications and reduced costs.
Clinic Quality Care
Our providers and clinic staff work together to deliver the best quality care to our patients. One of the tools we use is a system for previsit planning. Prior to your appointment, our staff will address with you a number of care items such as required screenings, important results, immunization status etc., in order to make the time you spend with our team more meaningful. The providers use the information from the previsit planning and from your appointment in order to prescribe the right treatment and ensure you receive the appropriate level of follow-up care.
Our facility focuses on preventing any unplanned returns to the hospital (readmissions) and preventing patient deaths by coordinating care-processes throughout our hospital and clinics.
Case Managers work with providers and clinics to make sure that our patients have all the required treatment resources available after they are discharged from the hospital (e.g. home health services, rehab and specialist appointments etc.) Patients receive handouts that help them meet and maintain their health goals, look up signs of worsening conditions, and know when to call the clinic or come directly to the Emergency Department.
Patients that suffer from chronic conditions like pneumonia, COPD, heart failure etc. are advised to follow-up with a specialist within 3-5 days after their discharge from the hospital and the plan of care is updated based on the patient’s condition.
These measures directly impact patients’ lives. It is important for patients to be aware of them and we encourage our patients and their families to speak up or ask any questions related to their healthcare. Asking questions is the best way to understand why certain tests are ordered, why treatments are given, and it allows the patient to be an active participant in planning their care.
- Because we believe that your care revolves around you, we want to hear from you and value any feedback, questions or desire to participate in improvement efforts in our hospital. We realize that no hospital is perfect; therefore, we have a Council made up of our senior most leaders that focuses on Performance Improvement. We can always do better and we want to hear from you! Please email us: