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Quality & Safety
About Our Report Card
How to Use Quality Report
Technical Notes
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Influenza and You 2013
Safe Practices


1. What is in this Quality Report?

Saint Joseph Health is displaying clinical outcomes (such as complication or readmission rates), volumes (number of procedures performed), clinical processes (such as how often patients get the recommended medicine), and patient satisfaction results.

Data - We display two types of data:

Numbers as rates, called "indicators," such as the percentage of patients who had a complication volumes or counts, numbers of patients who had a procedure, or developed a condition in the hospital.

Ratings - We rate our performance as explained below:

Indicators that are percentages or ratios. If national data are available for an indicator, we compare our performance to the national average and color-code our results: green if we are better than the national average, red if we are worse than the national average and gray if we are near the national average. We use standard statistical procedures to determine when to apply the color-coding, as described in Technical Notes. (Note: The hospital numbers in a particular row are compared to the U.S. average in that row. A percentage in one row cannot be validly compared to a percentage in a different row.)

Indicators that are number of procedures performed. We do not rate volume measures.

Safe practices. We are in the process of developing means of measuring our adherence to the NQF safe practices.  Right now, we just list the practices.

Pop-ups. Throughout the report, links and "pop-up" boxes may be activated by pointing and clicking with your mouse. For example, you can click on an indicator description or number, and a temporary box will open that provides additional explanation.

2. How were these quality indicators and safe practices selected?
National organizations have endorsed lists of quality indicators and safe practices. We address every hospital item on each endorsed list; we do not select only certain items. All the indicators or safe practices have extensive research to support their use and are defined so that all hospitals can use the same method for calculating the statistics. Reporting methods are "open," which means anyone can see how the results were obtained. The details of the organizations and their endorsed lists are in Technical Notes.

Indicators and safe practices are not perfect, however. We do not agree that all the items we are reporting are valid assessments of important quality issues. Even for such items, however, we use the national definition and report our performance. This full reporting is our assurance to you that we are not selectively reporting only our strengths. Further discussion of the limitations of indicators is in Technical Notes.
3. Does this Quality Report display data about individual physicians?

No. We are publishing hospital and facility data only.
4. Is this information available for hospitals that are not part of Saint Joseph Health?

Generally not. Most of the clinical information displayed here is not currently publicized by other hospitals. Data for patient satisfaction and for some of the outcome and process measures for heart failure, heart attack, pneumonia, and surgery indicators can be found at Hospital Compare. Saint Joseph Health also voluntarily posts the limited data requested on that site, but the information we're displaying in this report is much more comprehensive and more up-to-date.

The Kentucky Hospital Association has begun to publish data about the charges and quality of Kentucky hospitals. Saint Joseph Health is a strong supporter of this increasing "transparency" about hospital performance.

Average indicator performance for hospitals in Kentucky (KY) and for the nation (U.S.) is displayed, if available. Obviously, those averages do not represent the performance of any individual hospital.
5. Why is Saint Joseph Health publishing its quality data?
We like what open reporting does for you. As a not-for-profit health care system and a community resource, we believe that you should know how we are performing. We want patients and families to have better information about the quality of healthcare in Kentucky.

We like what open reporting does for us. Public reporting helps us document our care more carefully, obtain more valid data, and give better patient care than we do without public reporting.

We like what open reporting does for hospital care in general. We hope that our Quality Report will contribute to a better understanding of how to assess, report, and improve hospital quality. We welcome the chance to collaborate on better methods for making hospital quality data public.
6. What does "risk-adjusted" mean?

The risk of a complication or death varies by patient and by procedure. For example, an older surgical patient who has complicating illnesses such as kidney failure and diabetes is at greater risk of developing complications than a young, healthy patient is. Open heart surgery has a greater risk of a collapsed lung than knee surgery does.
Risk adjustment mathematically takes into account differences in patient and procedure risk factors, so that comparisons are more meaningful. Risk adjustment allows for comparison of actual performance with predicted performance, based on the average U.S. hospital. More details of risk adjustment are explained in Technical Notes and on the sites of the national organizations that endorsed these indicators.
7. If a hospital's performance is red, does that mean it provides bad care?

It's not that simple.

There are many possible reasons that performance on an indicator might be red. (Turn these around to consider reasons that performance on an indicator might be green.)

Here are a few:

  • The hospital may provide care that is worse than the national average.
  • About half the hospitals in the U.S. will be worse than average on any given indicator. No one wants to be worse than average, but even performance that is significantly worse than the national average may still be well within the range of good care.
  • The hospital may do a better job than other hospitals of detecting and reporting infections or complications.
  • The hospital may do a worse job than other hospitals of detecting and reporting risk factors, so the hospital is not getting full credit for the complexity of its cases.
  • The indicator may do a poor job of capturing what it's trying to measure.
  • Indicators that are especially likely to be weak in this regard include those based only on number of procedures and those based on billing data (the AHRQ Patient Safety Indicators and Inpatient Quality Indicators use billing data).
  • The indicator's risk adjustment statistical model may not take into account all the factors that it should, so the hospital is not getting full credit for the complexity of its cases.

For additional information, see Technical Notes, especially the section on Limitations of indicators.
8. How often will the data on this report be updated?

This report will be updated as often as new data become available, and at least quarterly.

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