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Measuring Quality

In order to tell if care
is getting better

Reporting Quality

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Quality & Accreditation Journey

Our history of pursuing excellence
in quality healthcare

Our Quality Recognition

Our quality Clinical Services have
been recognized by many

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Our Quality Initiatives

NYSPFP – New York State Partnership for Patients

NYSPFP is a program to improve patient care and outcomes in hospitals across New York State. A federal contract was awarded to the Healthcare Association of New York State (HANYS) and Greater New York Hospital Association (GNYHA) to assist hospitals in New York State to reduce preventable patient harm by 40% and readmissions by more than 20%. This is a two-year project which began in 2012.

ACS NSQIP – American College of Surgeons National Surgical Quality Improvement Program

The ACS NSQIP is the first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. This program collects data on 136 variables, including pre-operative risk factors, intra-operative variables, and 30-day, post-operative mortality and morbidity outcomes for patients undergoing major surgical procedures in both the inpatient and outpatient settings. St. Elizabeth Medical Center has been involved in this program since 2009.

NDNQI – National Database of Nursing Quality Indicators

The National Database of Nursing Quality Indicators is a system developed by the American Nurses Association (ANA) to enable hospitals to collect and evaluate nursing-sensitive indicators. NDNQI contains data collected at the nursing unit level for quality indicators such as falls and pressure ulcers. The nursing quality indicators are then compared to the
other hospitals in the national database.

NHSN – National Healthcare Safety Network

The NHSN is an internet –based surveillance system managed by the Centers for Disease Control and Prevention (CDC) for acute care facilities to report certain healthcare associated infections (HAIs) and other quality indicators. Some of the HAIs reported are central line associated bloodstream infections (CLABSIs), catheter associated urinary tract infections (CAUTIs), and any surgical site infections for colon surgeries and abdominal hysterectomies. The data from NHSN is publicly reported on the Hospital Compare website.

Bordering on Zero

Bordering on Zero (BOZ) is an American/Canadian patient safety collaborative, involving 14 New York hospitals and hosted/coached by the Ignite Team at University Health Network in Toronto, Ontario. Each site team has chosen its unit to begin with and patient safety issues on which to focus. For St. Elizabeth, it is infection prevention on 3A. The goal is to spread this idea to other units within the hospital. Teams across the collaborative are using innovative processes to engage front-line staff in making patient safety practice improvements. The serious, and seriously fun BOZ collaborative is sponsored and supported by Excellus Blue Cross/Blue Shield and is an opportunity for hospitals to improve patient outcomes and staff interaction.

Comprehensive Unit-Based Safety Program (CUSP)

CUSP is a Patient Safety Program developed at Johns Hopkins Medical Center which uses teams of front-line workers to develop safe practices and to integrate them into their daily work. Currently there are CUSP Teams in the ICU and Operating Room. The O.R. CUSP Team is part of the ACS NSQIP Program. St. Elizabeth was one of 5 hospitals in the U.S. and Canada chosen for this project, which was presented at the annual NSQIP Conference in San Diego, California in July, 2013.

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