Quality & Safety

Performance Excellence

Our Performance Excellence department is all over the hospital. It assists teams with identifying any potential patient safety issues, then helps them find solutions.

Fall Prevention

Falls can be a real danger, especially for patients who are trying to get up from their hospital beds. The Fall Committee at Stormont Vail leads efforts to eliminate patient falls. Each month, the department with the greatest improvement in fall reductions receives an award.

Patient Safety Leadership Rounds

We send safety professionals to get an up-close look at patient care areas. Each week, the Patient Safety Leadership team visits patient care areas and has a candid, confidential discussion with team members about potential safety issues — and ways to keep patients safe.

Disclosure of Errors/Transparency

We make sure you know where we stand with quality and safety. National agencies and patient surveys evaluate how well we meet quality and safety standards, as well as our patients’ opinions of us. Those results are then displayed online as a part of our effort to improve patient safety.

Centers for Medicare & Medicaid Services (CMS)

This federal agency runs the Medicare program. It also works with state governments to administer Medicaid. CMS sets standards of care for Medicare and Medicaid patients and reimburses health care providers for their care.

Agency for Healthcare Research and Quality (AHRQ)

This federal agency analyzes and publishes certain health care quality and safety survey results. The goal is to improve the quality of health care across the United States.

The Joint Commission

This organization has been accrediting hospitals for more than 50 years. Its accreditation is a nationwide seal of approval that indicates a hospital meets high quality standards. In addition, accreditation helps hospitals:

• Improve performance
• Raise the level of patient care
• Demonstrate accountability

To illustrate our commitment to excellent care, Stormont Vail Hospital is accredited by The Joint Commission. We also have additional Joint Commission accreditations in the following areas:

• Joint Commission Hospital Accreditation
• Advanced Primary Stroke Center
• Advanced Total Hip/Knee Replacement
• Chest Pain
• Perinatal Care
• NICU Prematurity

American Nurses Credentialing Center (ANCC)

This organization awards the prestigious Magnet® designation, one of the highest awards in nursing excellence and high-quality patient care. With only about 9% of US hospitals earning the Magnet designation, Stormont Vail Health has been honored with this recognition since 2009.

Additional Recognitions for Patient Safety

Additional certifications show our commitment to improving processes and establishing the best care possible for our patients.

• Trauma Level II (American College of Surgeons)
• Mammography (American College of Radiology)
• Cardiac Rehabilitation (American Association of Cardiovascular and Pulmonary)

Consumer Assessment of Healthcare Providers and Systems (CAHPS®)

This is a series of surveys that lets patients rate their health care experiences, including quality and safety.

The Centers for Medicare & Medicaid Services use the scores from some CAHPS surveys, along with other quality measures, to reward high-performing health care organizations.

Clinician & Group Consumer Assessment (CG-CAHPS)

Just as you might check reviews or share your own review for a restaurant or vehicle, you might do the same for your health care provider.

The 2017 Clinician & Group Consumer Assessment  (CG-CAHPS) is a survey that allows patients to give a review of their experience with Cotton O’Neil’s primary and specialty care clinic for outpatient services, such as check-ups, follow-up appointments, lab tests, or MRI scans. Here’s what our patients said:

• 81%: Percentage of patients who said office staff were helpful, courteous and respectful
• 85%: Percentage of patients who said their providers communicated well

The 2018 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

There are two HCAHPS surveys, one for adults and one for children. These surveys ask about the care delivered during an inpatient stay at Stormont Vail Hospital.

• 75% of patients gave Stormont Vail Hospital a rating of 9 or 10, on a scale of 0 to 10.
• 78% of patients said they would recommend Stormont Vail Hospital.

Community Health Needs Assessment

We don’t just look at our health system. We reach out to the community we live in,  and find ways to help. The Patient Protection and Affordable Care Act requires all nonprofit hospitals, such as Stormont Vail Hospital, to identify top healthcare issues in their communities every three years. Using data from our most recent 2019 assessment, we created the 2019 CHIP: Community Health Improvement Plan (CHIP).

Healthcare-Acquired Infections

Healthcare-acquired infections can occur when patients have an overnight hospital stay. They are considered a medical complication that many health care organizations must guard against.

Catheter-Associated Urinary Tract Infections

Stormont Vail Hospital has a lower-than-average rate for a very common healthcare-acquired infection, catheter-associated urinary tract infections (CAUTI). Catheters can become an easy way for germs to enter the body. So our hospital staff takes very careful steps to prevent infection.

• 0.6%: Stormont Vail Hospital CAUTI infection rate
• 0.8%: CAUTI infection rate at hospitals nationwide

Clostridium Difficile Infection (C. diff)

C. diff is a bacterium that infects the large intestine. This can lead to severe diarrhea. Through Stormont Vail Hospital’s Reaching Zero campaign – an aggressive education and training program – we are reducing the number hospital-acquired infections such as C. diff.

• 1.3%: Stormont Vail C. diff infection rate
• 0.9%: National average

Stroke Readmission Rate

Stormont Vail Hospital has a lower-than-average stroke readmission rate — how often patients return to the hospital soon after being discharged (11.6%).

• 11.6%: Stormont Vail stroke readmission rate
• 12.2%: Stroke readmission rate at hospitals nationwide