At BMC, our commitment to exceptional care includes a commitment to high quality of care and patient safety. This means:

  • Providing care to ensure the best possible health outcomes. The goal is to ensure that all patients receive the best care possible for their condition and have equal access to evidence-based treatments, therapies, and medical care.
  • Keeping patients safe by preventing harm that can occur while receiving medical care. Our goal is to achieve zero harm to all patients.

Providing high-quality and safe care means not only avoiding harm for patients, but also providing care in a timely way, using only evidence-based care, and ensuring that care is respectful and responsive to a patient’s needs and preferences. At BMC, we are committed to meeting these goals for all patients, without exception. 

All of our staff and providers – regardless of role – play an important piece in providing safe and quality care. Therefore, everyone at BMC is empowered to bring their unique experience, skills and insight to improve care and prevent patient harm through each interaction on a daily basis. We also strongly encourage you to actively participate in all aspects of your care at BMC, to help ensure your needs are met.

While BMC prides itself on providing safe and quality care, we know there is always room for improvement, and that improving quality and patient safety depends on regular measurement and tracking outcomes. To this end, Boston Medical Center has a robust quality and patient safety program that identifies our areas of strength and our areas for improvement, and uses evidence-based methods to make and sustain improvements throughout all areas of the hospital.

Quality: External Facing Metrics

Mortality

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: 

Measure BMC July 2016-June 2019 National Average*
30 day adjusted heart attack mortality rate No different than national rate 12.7%
30 day adjusted heart failure mortality rate Better than national rate 11.3%
30 day adjusted pneumonia mortality rate No different than national rate 15.4%
30 day adjusted stroke mortality rate No different than national rate 13.6%
30 day adjusted chronic obstructive pulmonary disease mortality rate No different than national rate 8.4%
30 day adjusted coronary artery bypass grafting mortality rate No different than national rate 3%

*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. 
  • Review overall mortality data to identify areas of focus and potential opportunity to improve care delivery.

Readmissions

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:

Measure BMC July 2016-June 2019 National Average*
30 day adjusted heart attack readmission rate No different than national rate 16.1%
30 day adjusted heart failure readmission rate No different than national rate 21.9%
30 day adjusted pneumonia readmission rate No different than national rate 16.6%
30 day adjusted chronic obstructive pulmonary disease readmission rate No different than national rate 19.6%
30 day adjusted coronary artery bypass grafting readmission rate No different than national rate 12.7%
30 day adjusted readmission rate following elective total hip replacement and/or total knee replacement surgery No different than national rate 4%
30 day adjusted Hospital-Wide All Cause Unplanned readmission rate No different than national rate 16.6%

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.

Quality: Internal Facing Metrics

Hand Hygiene

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:

Hand Hygiene Observation Compliance

What we are doing to improve:

  • 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.

Patient Safety

Taking care of sick patients requires many people and systems to work together to give the best and safest care possible. At BMC, we work hard every day to keep patients safe from harm. On very rare occasions, something happens that was not intended.  We study these events to learn how to make our systems safer. We collect information on safety events and use this information to make improvements.

Hospital Acquired Infections

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:

Measure BMC January –December, 2019 National Ratio*
Central line-associated bloodstream infections in intensive care units and select other patient units No different than national rate 0.685
Catheter-associated urinary tract infections in intensive care units and select other patient units No different than national rate 0.718
Surgical site infection from colon surgery No different than national rate 0.867
Methicillin-resistant Staphylococcus Aureus (MRSA) blood infections No different than national rate 0.821
Clostridium difficile intestinal infections No different than national rate 0.582

*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.

Patient Safety Indicators (PSI-90)

What the measures mean: PSI-90 is a group of measures that relate to a set of potentially preventable events that are associated with harmful outcomes for patients, such as pressure injuries, in-hospital falls with hip fracture, post-operative sepsis, respiratory problems, kidney injury and wound separation, peri-operative blood clots or bleeding.

BMC Performance:

Measure BMC July 2017-June 2019 National Ratio
PSI-90: Patient Safety and Adverse Events Composite No different than national rate 1.0

What we are doing to improve: Using several best practices for prevention of the complications in the PSI-90 measure group, BMC provides care that will help patients avoid these harms. For example, to prevent blood clots in the lung or large veins after surgery, patient risk levels are identified and medicine may be given for prevention.

Perinatal Care

Doctors and hospitals can improve chances for a safe delivery and a healthy baby by providing care that will promote optimal outcomes. 

What the measure means: Early elective delivery is defined as delivery by induction of labor without medical necessity followed by vaginal or caesarean section delivery or a delivery by caesarean section before 39 weeks gestation without medical necessity.

BMC Performance:

Measure BMC January –December, 2019 State Rate National Rate
Percentage of mothers whose deliveries were scheduled too early (1-2 weeks), when a scheduled delivery wasn’t medically necessary Better than State and National rates 1% 2%

What we are doing to improve: Interventions are in place to only perform induction of labor and caesarean delivery at the optimal time for safe care, unless medically necessary to perform earlier.

Healthcare Personnel Influenza Vaccination

Flu is a contagious disease that spreads around the United States every year, usually between October and May. While anyone can get the flu, but it is more dangerous for some people than others. Each year, thousands of people in the US 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:

Measure BMC 10/1/2019-3/31/2020 MA Adherence Rate National Adherence Rate
Influenza Vaccination Coverage among Healthcare Personnel Better than MA and National rates 96% 91%

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.

Accreditation & Regulatory Compliance

State and federal agencies, as well as medical specialty societies, require that health care systems meet certain essential criteria to maintain accreditation, specialized certifications, and licensure. The Joint Commission surveys BMC every three years for overall hospital/ambulatory accreditation. In addition, the hospital goes through several accreditation/regulatory visits each year. The regulatory compliance division staff also work to coordinate the institutional response to device recalls.

Center for Medicare and Medicaid Services

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

The Joint Commission

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.

Comprehensive Stroke Certification (CSC) Joint Commission

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

Commission on Cancer

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.

Massachusetts Department of Public Health (MDPH)

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).

QI Hub: Quality Improvement Training

Jointly provided by the Department of Quality and Patient Safety and the Barry M. Manuel Continuing Medical Education Office, the QI Hub is the Boston Medical Center Health System’s educational home for continuous professional development in process and quality improvement.

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