LVMC Strives to Improve Quality and Patient Safety
Lompoc Valley Medical Center (LVMC) is committed to providing transparent, useful information to consumers about the quality of its care. This Hospital Quality Institute outlines LVMC’s performance on several recognized quality indicators critical to patient care. We at LVMC strive to continually improve our quality of care and believe providing accurate, detailed information about key quality indicators is critical to that goal.
The Hospital Quality Institute provides support for improvement measures for patient safety and quality improvement activities for the California Hospital Association and others. As consumers can see, the outcome measures are tallied so that a lower score is better. Readers can compare LVMC’s ratings with the California level and the National level. LVMC proudly participates in quality and patient safety initiatives, including the development of an interdisciplinary Sepsis Committee overseeing outcomes and implementation of best practices in the management of patients with sepsis. LVMC participates in Quest for Zero Patient Harm, in collaboration with Beta Healthcare Group in the areas of Emergency and Perinatal Care.
In these reports, consumers will see that LVMC has in place:
- A Maternity Safety Program in response to risks associated with pregnancy and childbirth
- A Sepsis Protocol to provide guidance for a coordinated approach to identification and treatment of an infection and inflammatory response which is present throughout the body
- A Respiratory Monitoring Program to provide guidance for the assessment of the risk of respiratory depression and includes continuous monitoring of breathing and functioning of the lungs and circulatory system.
Quality Indicators allow LVMC to study data for ways to improve and standardize our practices, to ensure superior quality of care for every patient.
Outcome Measure Definitions
|CLABSI - Central line-Associated Blood Stream Infection: A serious infection that occurs when germs enter the bloodstream through a central line. A central line is a special intravenous catheter (IV) that allows access to a major vein close to the heart and can stay in place for weeks or months. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitations: In the calculation of the Standardized Infection Ratio (SIR), the CDC adjusts for differences between hospitals. However, patient risk factors are not taken into account. These patient-specific variables (e.g., poor skin integrity, immunosuppression) can increase the risk of developing a central line infection. Hence, the SIR for hospitals that care for more medically complex or immunosuppressed patients may not be adequately adjusted to account for those patient-specific risk factors.|
|Colon SSI - Colon Surgical Site Infection: An infection (usually bacteria) that occurs after a person has colorectal surgery that occurs at the body site where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, organs, or implanted material. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitations: Some, but not all patient-specific risk factors are included in the adjustment of the SIR for these types of infections. However, not all relevant risk factors are included (e.g., trauma, emergency procedures). Hence, the SIRs for hospitals performing more complex procedures or with larger volumes of trauma or emergency procedures may not be adequately adjusted to account for those patient-specific risk factors|
|NTSV - Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate: The percentage of cesarean (surgical) births among first-time mothers who are at least 37 weeks pregnant with one baby in a head down position (not breech or transverse). Lower values indicate that fewer cesareans were performed in the hospital among primarily low risk, first-time mothers. Limitations: NTSV rates do not take into account certain obstetric conditions, such as placenta previa, that may make Cesarean delivery the safer route for both mother and infant.|
|Sepsis Mortality: Percent of patients, with a severe infection, who die in the hospital. Most sepsis cases (over 90%) start outside the hospital. Lower percentage of death indicates better survival. Limitations: Use of discharge/administrative data is limiting since such data has lower specificity for diagnoses than clinical data. In addition, without risk adjustment for differences in patient-specific factors, comparing rates among hospitals is difficult.|
|30-day Readmission - Hospital-wide All-Cause 30-day Unplanned Readmission Rate: The percentage of patients who were unexpectedly readmitted within 30 days of discharge from the hospital for any reason. Lower values indicate that fewer cases were unexpectedly readmitted after discharge. Limitations: Some, but not all patient-specific risk factors are included in the adjustment of the readmission rate. However, not all relevant risk factors are included (e.g., trauma, emergency procedures).|