FREQUENTLY ASKED QUESTIONS & ANSWERS

 

1.  What is in this report?

BroMenn Healthcare System will display both clinical results (i.e., patient care measures and outcomes) and patient satisfaction results in this report.  The hospital’s financial data is not included in this report.  Information you can find in this report includes:

Data – Data are numbers that may be shown as a percentage, timeframes such as minutes, or an index where 1.0 is used as a marker.  When indexes are used, numbers less than 1.0 indicate a percentage below (better than) the index and numbers greater than 1.0 indicate a percentage above (worse than) the index.

Ratings – Ratings is performance expressed as a percentage, ratio or number of procedures performed.

 

2.  How were the indicators and safe practices within the report  selected?

National organizations have endorsed a number of quality indicators and safe practices.  All the indicators and safe practices used within this report have been extensively researched to support their use and are defined by the endorsing organization so all hospitals can use the same method for calculating results.   Indicators utilized at this point in time are drawn largely from those endorsed by the National Quality Forum, Medicare, the Centers for Disease Control and Prevention, The Joint Commission, and the Illinois Department of Public Health.

 

3. Does the report display data for individual physicians?

No.  BroMenn is publishing hospital data only.

 

4. Why is BroMenn Healthcare publishing its data?

BroMenn Healthcare advocates for sharing information about hospital performance.  As a major healthcare provider and resource within the community, we believe our patients and their families should know how we are performing.  We want them to have information about the quality of healthcare provided regionally, within the state and the nation. 

We believe public reporting will help us to document our care more carefully and will help us to give better patient care than we would have without public reporting.  We believe our Quality Report also supports the healthcare industry in its efforts to learn how best to assess, report, and improve hospital quality.  We are committed to providing better information about healthcare quality to those utilizing our services, and we welcome the opportunity to participate in the identification of new and better ways to make hospital quality data public.

5. Does the data in this Quality Report encompass care provided at Eureka Community Hospital?

No.  This report provides data only for care provided at BroMenn Regional Medical Center.  In the future data specific to Eureka Community Hospital may be added.


6. What does risk-adjusted mean?

The risk of a complication or death varies by patient and by procedure.   For example, an older patient who has complicating illnesses such as kidney disease, heart disease and/or diabetes is at greater risk of developing complications during hospitalization than a young, healthy patient is.  Similarly, certain procedures carry more risk for complications than others.

Risk-adjustment mathematically takes into account differences in patient and procedure risk factors so comparisons can be more meaningfully made.  Typically, risk-adjustment allows for a comparison of actual performance with predicted performance based on average hospital performance within a particular grouping of hospitals and using a specific risk-adjustment model.  When risk-adjustment is utilized, details regarding the risk-adjustment model and methodology are typically made available by the organization endorsing the indicator.


7. If a hospital’s performance is below the national average, does that mean it provides bad care?

Not necessarily.  There may be many reasons for a performance indicator to be low. Here are a few possibilities:

  • No one wants to be lower than average; however,  hospitals noted as providing care significantly worse than the national average may still be providing care well within the range of good care.  About half the hospitals in the US will be lower than average on any given indicator.
  • One hospital may do a better job than another of detecting and reporting infections and/or complications
  • One hospital may do a worse job than another of detecting and reporting risk factors used for risk-adjustment, causing the hospital to not receive full credit for the complexity of its cases
  • The indicator may not do a good job of capturing what it is actually trying to measure.  Within the healthcare industry, indicators weakest in this regard tend to be those based solely on billing data (for example, many of the current mortality and other Agency for Healthcare Research & Quality patient safety and quality indicators)
  • The risk-adjustment model may not take into account all the factors needed to capture the full complexity of each case, causing the hospital to not receive full credit for the complexity of its cases

8. How often will data on the report be updated?

This report will be updated as new data becomes available.