Calidad y Seguridad del Paciente

What the measure means: The mortality rate looks at how many patients die in the hospital compared with the expectation of continued survival, which depends on how severe their conditions are.  

BMC Performance: 

* Source: Center for Medicare and Medicaid Services/Hospital Compare

What we are doing to improve:

• Reviewing all mortality cases to ensure high quality care was given.
• Improving the timeliness of early recognition and treatment of sepsis, both when present on admission and when it develops after admission. 
• Reviewing overall mortality data to identify areas of focus and potential opportunities to improve care delivery.

What the measure means: Our goal is that once a patient is discharged from a hospital stay, they will have a plan of care and any needed outpatient services that will help ensure they will not need to return to the hospital within a month for an unplanned visit. This measure looks at how many patients do need to return for a second inpatient stay within 30 days.

BMC Performance:

What we are doing to improve:

• Ensuring timely outpatient contact with providers for patients with conditions that make them more likely to have to return to the hospital.
• Discharging patients with easy-to-understand instructions, using their preferred language, pictures, charts, etc.
• Arranging outpatient care and services to meet patient needs in their community.

What the measure means: Proper hand hygiene is a necessary action to help stop the spread of germs. Staff and providers conduct weekly observations of hand hygiene across the hospital to identify performance.

BMC Performance: Staff and clinician hand hygiene performance consistently exceeds targeted compliance rate.

What we are doing to maintain excellence in compliance:

• Hand sanitizer is located inside and outside patient rooms for easy access for staff and visitors. Dispensers are routinely monitored to make sure they are filled and working.
• Sinks are located inside or close to patient rooms for times when soap and water handwashing is required. Soap dispensers are routinely monitored to make sure they are filled and working.
• If needed, staff are encouraged to remind each other to complete hand hygiene.
• Patients and visitors are encouraged to ask staff and providers if they have used hand hygiene.
• Staff and providers receive regular education on proper hand hygiene techniques.
• For specific hand hygiene needs, signs are posted on patient doorways.
• All units receive regular reports of their performance. Leadership immediately acts on any identified gaps in compliance.

What the measures mean: When patients are sick, they may need to have devices, such as urinary catheters or central venous lines, to help them get better. These devices have some risks, such as infection. While infections are largely preventable, they may happen in some complex patient situations, despite meticulous care and treatment.  

Likewise, other treatment to help patients return to health, such as antibiotics, also have some associated risks. For example, Clostridioides difficile (C-diff) is a type of bacteria that may be associated with antibiotic use.

BMC Performance:

* Infections are reported using a standardized infection ratio (SIR). The SIR compares the actual number of infections at a hospital to a national benchmark based on data reported to the National Healthcare Safety Network (NHSN).

What we are doing to improve:

• Ensuring high compliance with proper hand-washing, before and after patient care.
• Making every attempt to not use these devices whenever possible and if needed, remove them as soon as possible.
• Always using the best possible technique to put devices in.
• Consistent use of best possible care for maintaining devices.
• Learning from each situation in which an infection occurs to continually improve our system of care.
• Careful attention to ensuring best practices for antibiotic stewardship.

Flu is a contagious disease that spreads around the United States every year, usually between October and May. While anyone can get the flu, it is more dangerous for some people than others. Each year, thousands of people in the United States die from the flu and many are hospitalized. Flu vaccine prevents millions of illnesses and flu-related visits to the doctor every year.

Healthcare staff and providers promote preventative behavior through role modeling and by providing education about preventative services.

BMC Performance:

What we are doing to improve: 

• Every year in October, influenza vaccine is readily available to staff and providers. 
• Adherence data is consistently monitored and staff are personally engaged for compliance.

BMC is certified as a Medicare and Medicaid hospital provider. The Massachusetts Department of Public Health carries out certification surveys on behalf of CMS.

BMC is accredited by The Joint Commission’s Hospital Accreditation Program, an independent nonprofit organization that evaluates healthcare organizations on specific quality and patient safety standards.

BMC is recognized as a hospital that has the specific services, resources, staff expertise, and training required to treat complex stroke.

BMC’s Cancer Center is accredited by the American College of Surgeons Commission on Cancer. Accreditation recognizes the Cancer Center’s commitment to comprehensive and patient-centered care, a multidisciplinary approach, clinical trial access, lifelong patient follow-up, psycho-social support, and continuous quality improvement.

BMC complies with all regulations under Massachusetts general law related to hospital licensure and healthcare facility reporting, including the reporting of serious reportable events (SREs).