Page 13 - 2020 ARE eGuide for Clinical at Hospital Sites

Overview

Quality Measurement at Baptist Health

Baptist Health is required to report various performance measures to
the Centers for Medicare and Medicaid Services (CMS) and to the Joint
Commission (TJC) on an ongoing basis.
Examples of these reported measures take into account specific criteria
regarding quality, safety, as well as the overall experience of the patient's
care. CMS publicly reports facility information regarding quality of care on
their consumer-oriented website, HospitalCompare.
While CMS and TJC will modify and/or retire specific measures over time,
Baptist Health firmly supports the use of evidence-based practices
regardless of current external reporting requirements. Including TJC, some
of the ways we learn how we are performing compared to other healthcare
facilities is through performance measures and the surveys below:
• National Quality Measures (NQMs)
• Outcomes Measures
• Hospital-Acquired Conditions (HACs) includes:
• Healthcare-Associated Infection Measures
• Patient Safety Indicators (PSI) Measures
• Patient Experience Surveys, including the Consumer Assessment of
Healthcare Providers Surveys (CAHPS)
With ongoing changes due to healthcare reform, Baptist Health's ongoing
compliance and successful performance in various CMS programs, such as,
Hospital Value-Based Purchasing, Hospital Readmissions Reduction, and
Hospital-Acquired Condition (HAC) Reduction, impacts the organization's
reimbursement and reputation.