Our Commitment to Quality

Identifying the right healthcare provider for your needs is an important decision. A number of sources exist for comparing hospital quality. Among these, the Centers for Medicare and Medicaid Services (CMS), an agency of the United States Department of Health and Human Services, offers quality measures that illustrate how often hospitals provide some of the recommended care to get the best results for most patients. To learn more visit www.hospitalcompare.hhs.gov.

Saint Francis Health System is accredited by the Joint Commission. Entities participating in the survey completed in 2005 were:

Saint Francis Hospital
Saint Francis Hospital at Broken Arrow
Laureate Psychiatric Clinic and Hospital
Saint Francis Skilled Nursing
Saint Francis Home Health
Saint Francis Hospice

In addition to the quality initiatives required to maintain Joint Commission accreditation, a number of quality initiatives are ongoing within the Saint Francis Health System, many based at Saint Francis Hospital and extending to other entities as appropriate. Among them:

CMS/Premier Hospital Quality Improvement Demonstration Project
Saint Francis Hospital and Saint Francis Hospital at Broken Arrow are among approximately 270 hospitals around the country participating in an innovative pilot program as part of the CMS move towards a national Pay for Performance program. Pay for Performance provides payment incentives for those organizations which exceed quality goals set by CMS. The program is designed around evidence-based interventions to improve treatment for the following diseases:

Heart Attack Care
Heart Bypass Surgery
Heart Failure Care
Pneumonia Care
Hip & Knee Surgery

Physician-led task forces of the Clinical Monitoring Committee and interdisciplinary teams work together to develop improvement projects in each of these areas.

Hospital Quality Alliance (HQA)
Saint Francis Hospital participates with approximately 4,000 other hospitals in the Hospital Quality Alliance. This project follows the same quality measures as the CMS/Premier Demonstration project for Heart Attack, Heart Failure and Pnuemonia. Results are available for the public to see by hospital and with national and state averages at the CMS website.

Surgical Care Improvement Project (SCIP)
Saint Francis Hospital is one of 8 Oklahoma hospitals to be selected to participate in the new Surgical Care Improvement Project. The goal of this national project is to reduce preventable surgical morbidity and mortality by 25 percent by 2010. Interdisciplinary teams, including a physician-led steering committee, are in place to measure and improve performance in the following areas:

Surgical infection prevention
Cardiovascular complication prevention
Venous thromboembolism prevention
Respiratory complication prevention

Measurement data from this new project will be used as it is developed to improve surgical services provided to our patients.

Appropriate Care Measures (ACM)
Saint Francis Hospital is one of 17 Oklahoma hospitals selected to participate in the new Appropriate Care Measures Project. This national project is to improve the quality of care provided to heart attack, heart failure and pneumonia patients. The measurement sets are patient-centered and measure whether each patient received all of the evidence-based process measures indicated for their condition. When these "all or nothing" measurements become available, they will be used by Saint Francis Hospital's ongoing improvement teams and task forces to improve the quality of care delivered to our patients.

Patient Satisfaction
Saint Francis Hospital measures patient satisfaction through a survey system developed by Professional Research Consultants Inc. A random sample of discharged patients are surveyed each week by telephone and the percent of patient responses of "Excellent" are compared against other PRC client hospitals around the country. Survey results are presented monthly to staff and management and help direct efforts to improve the patient experience at Saint Francis Hospital. Similar surveys are conducted with patients at Saint Francis Hospital at Broken Arrow, Laureate Psychiatric Clinic and Hospital and patients seen through Warren Clinics.

Awards were given for 2005 scores that were in the top 25 percent of PRC clients for inpatient services, outpatient services and outpatient surgery. Surgical and pediatrics specialty units also won awards for scores in the top 10% (above the 90th percentile). A special award was given to the Eastern Oklahoma Perinatal Center (EOPC) for achieving the top patient satisfaction score of any pediatrics unit surveyed by PRC in 2005. Other awards included:

Top 10% awards were given to Saint Francis Hospital at Broken Arrow Outpatient Surgery and Inpatient Acute Care and to Warren Clinic’s Pediatric Oncology clinic and two physician offices.
Top 25% awards were presented to Saint Francis Hospital’s inpatient care, outpatient services, outpatient surgery and The Children’s Hospital Urgent Care Clinic. Saint Francis Hospital at Broken Arrow received top 25 awards for inpatient care, emergency department and outpatient services. Three Warren Clinic offices received top 25% awards.

Surgery for Obesity (Bariatric) Center of Excellence
Saint Francis Hospital recently received designation as a level 1b American College of Surgeons Bariatric Center of Excellence. Receiving this recognition demonstrates that the hospital can manage the most challenging and complex bariatric patient with optimal opportunity for safe and effective outcomes.

Getting with the Guidelines Stroke Project
Saint Francis Hospital has a designated stroke coordinator to provide identified stroke patients with a collaborative and coordinated approach to recovery. The Premier Perspective database provides ongoing clinical performance feedback and database top performer comparisons for key indicators.

Surviving Sepsis Improvement Project
Saint Francis Hospital has engaged in implementing the “Surviving Sepsis” Campaign guidelines. Severe sepsis (infection-induced organ failure) is a common problem with a prevalence of 2.26 cases per 100 hospital discharges. It is frequently fatal with mortality rates remaining between 30 to 50 percent. The Surviving Sepsis Campaign (SSC) provides evidence based guidelines for management of severe sepsis and septic shock. Saint Francis Hospital has a multidisciplinary task force that is piloting implementation of these guidelines.

National Database of Nursing Quality Indicators (NDNQI)
Saint Francis Hospital participates as a member of the National Database of Nursing Quality Indicators (NDNQI). It is a proprietary database of the American Nurses Association which collects and evaluates unit-specific nurse-sensitive data from hospitals in the United States. There are 904 hospitals participating in the data base with approximately 20 percent (177) Magnet status facilities.

Participating facilities receive unit-level comparative data reports to use for quality improvement purposes. The database provides measurement and comparison regarding nursing sensitive outcomes e.g. pressure ulcers, and falls.

Saint Francis Hospital has used data comparison for benchmarking skill mix, and nurse sensitive outcomes. Saint Francis Hospital performed well compared to the national mean in nurse sensitive outcomes for facility acquired pressure ulcers and moderate to severe injury rates for falls.