Quality & Safety > Quality & Patient Outcomes

Web Content Viewer (JSR 286)


Quality & Patient Outcomes

Kuakini Medical Center is required to maintain a system of review to determine and monitor the medical appropriateness, medical necessity, and proper use of hospital (acute care) services and programs as mandated by the Federal and State government, commercial health insurance plans, The Joint Commission, and other licensing/accreditating organizations

Your hospital stay and care will be reviewed continuously under this monitoring system by Kuakini's Quality and Patient Outcomes Department. This department will determine when you no longer need acute care services and ensures that the care you receive meets national quality standards. The Medical Social Workers and Care Management staff will provide you with discharge planning support. The patient review system is an important part of Kuakini's effort to provide quality care and to contain health care costs.

Patient Experience Surveys

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) – a national hospital survey required by Centers for Medicare and Medicaid Services (CMS) that randomly surveys Medicare/Medicaid patients regarding their experiences with the following measures during their recent hospitalization:

• Cleanliness of Hospital Environment
• Communication about Medicines
• Communication with Nurses
• Communication with Doctors
• Discharge Information
• Overall Rating of this Hospital
• Pain Management
• Quietness of Hospital Environment
• Responsiveness of Hospital Staff
• Willingness to Recommend this Hospital

Press Ganey – A national health care performance company that sends random surveys to discharged hospital patients to gauge patient satisfaction with the following hospital services:

• Admission
• Emergency Room
• Room
• Meals
• Nurses
• Tests and Treatments
• Visitors and Family
• Physician
• Discharge
• Personal Issues
• Overall Assessment

Core Measures

The following quality measures are established by CMS for national review and benchmarking of U.S. hospitals’ performance and linking the hospitals’ performance to Medicare payments to hospitals.

• Acute Myocardial Infarction
• Heart Failure
• Pneumonia
• Surgical Care Improvement / Surgical Infections Prevention (SCIP)
• Emergency Department (ED) Throughput

Hospital Acquired Infections and Conditions

• Central Line Associated Bloodstream Infections (CLABSI)
• Foreign Object Retained After Surgery
• Air Embolism
• Blood Incompatibility
• Pressure Ulcers State III & IV
• Falls / Trauma
• Vascular Catheter Infections
• Catheter Associated Urinary Tract Infection (CAUTI)
• Poor Glycemic control

Hospital Mortality

Hospital Readmissions (within 30 days of discharge)

Kuakini Geriatric Care, Inc.

Department of Health Survey – The state annually surveys the long term care facilities

Nursing Home Compare – The long term care facilities are assessed by CMS based on the following measures.

Leapfrog Survey

Kuakini Medical Center's response and request to the Leapfrog Group - October 22, 2012

Kuakini Medical Center's request to the Leapfrog Group for correction of source data - April 6, 2013

Leapfrog Group response - April 19, 2013

Glossary of Terms

Definitions of terms used in the various surveys of hospitals and long term care facilities.