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Our Quality Measures

The Joint Commission and the Centers for Medicare & Medicaid Services have developed certain standards of care that help hospitals and physicians keep up-to-date with the best scientific-based medical practices, and measure how well we have adopted these practices.  These are commonly referred to as “core measures,” and relate to treatments for heart attack, heart failure, pneumonia and surgical care.  When these standards of care are followed for any appropriate patient, it is more likely the patient will experience a positive outcome and recovery.

Heart Attack

A heart attack, or acute myocardial infarction (AMI), occurs when an artery of the heart becomes blocked and causes the blood and oxygen supply to part of the heart muscle to slow down or stop. This may cause the affected heart tissue to die. The standards of care developed to measure the outcomes of heart attack patients include the speed in which certain medications are given, types of medications and discharge processes.

Congestive Heart Failure

Heart failure occurs when the heart’s pumping power weakens, causing the body to not get sufficient oxygen and nutrients. The standards of care used for most adults with heart failure include specific evaluations, medications and discharge instructions.


Pneumonia is a serious infection that develops when the lungs fill with mucus. This infection causes cough, difficulty breathing, fever and fatigue. Appropriate patient assessment, blood cultures and antibiotics are some of the standards of care measured in pneumonia patients.

Surgical Care

Reducing the risk of infection after surgery is the primary goal of the surgical care quality measure. Specific standards of care performed at hospitals have been identified to reduce risk of infection and provide the best results for most patients. Some of the standards that are measured are the timeliness of:

  • Beginning antibiotics before surgery
  • Stopping antibiotics after surgery
  • Removing catheters used to drain the bladder after surgery
  • Keeping patient temperature and blood sugar at normal levels.

In addition to the core measures, patient satisfaction also is a standard for measuring quality of the patient experience. We survey patients about their personal experience in our hospital to help us learn where we may need to improve and what we should not change.