Patient Experience of Care Survey Results

Hospital Consumer Assessment of Healthcare Providers and Systems (Inpatient)

UC IRVINE MEDICAL CENTER
HCAHPS QUESTION DESCRIPTION (April 2016 - March 2017) NATIONAL AVERAGE
Lower is Better Higher is Better
Patients who reported that their nurses “always" communicated well 77% 80%
Patients who reported that their doctors "always" communicated well 81% 82%
Patients who reported that they "always" received help as soon as they wanted 66% 69%
Patients who reported that their pain was "always" well controlled 68% 71%
Patients who reported that staff "always" explained about medicines before giving it
63% 65%
to them
Patients who reported that their room and bathroom were "always" clean 75% 74%
Patients who reported that the area around their room was "always" quiet at night 59% 63%
Patients who reported YES, that they were given information about what to do during
88% 87%
their recovery at home
Patients who “strongly agree" they understood their care when they left the hospital 58% 52%

Patients who rated their hospital a 9 or 10 on a scale from 0 (lowest) to 10 (highest) 78% 73%
Patients who reported YES, they would definitely recommend the hospital 80% 72%

What are we doing to improve:

UC Irvine Medical Center strives to provide the best patient experience possible. Communication is key to creating a positive experience. We
provide families with the opportunity to meet with the nursing team at the bedside and ask questions. Our nursing staff is trained on best
practices to improve communication skills with patients. An improved call light process has been implemented to ensure patients always receive
assistance when needed.
National average Data Source:
Based on the national average from the Centers for Medicare & Medicaid Services (CMS ) Inpatient Quality Report.
Patient Experience of Care Survey Results
Clinician and Group Consumer Assessment of Healthcare Providers and Systems (Outpatient)

UC IRVINE MEDICAL CENTER

WHAT OUR PATIENTS SAY ABOUT US (April 2015 – March 2017) NATIONAL AVERAGE
Lower is Better Higher is Better
Patients who gave their doctors a rating of 9 or 10 on a scale from 0 (lowest) to 10
85% 87%
(highest).
Patients who reported YES, they would recommend the provider office. 89% 92%

Patients who reported YES, their doctors always communicated well. 91% 93%
Patients who reported that office staff members were always helpful and treated
91% 94%
them with courtesy/respect.

What are we doing to improve:

UC Irvine Medical Center clinics are streamlining appointments to allow patients more time with their physician. Nurses are now available to
answer calls with any important questions regarding prescription refills and care needs. Patients are now able to make follow-up appointments
immediately after visiting their doctor.

National Average Data Source:

Based on the 75th percentile Top Box % average from Press Ganey National Facilities CGCAHPS % Benchmark Report. Performance data is only available through CMS.
Use of Medical Imaging – Outpatient Imaging Efficiency
UC IRVINE MEDICAL CENTER
NATIONAL AVERAGE
MEASURE DESCRIPTION (July 2014 – June 2015)
Lower is Better Higher is Better
Use of Medical Imaging
Outpatients who had MRI lumbar spine for low back pain 37% of 54
40%
patients
Outpatients who had a follow-up mammogram, ultrasound or breast MRI within 10% of 727
9%
45 days after a screening mammogram. patients
Outpatients with CT scans of the chest that were “combination” (double) scans.
0% of 1,663 scans 2%
(Thorax CT - use of contrast material)
Outpatients with CT scans of the abdomen that were “combination” (double)
6% of 1,557 scans 8%
scans. (Abdomen CT - use of contrast material)
Outpatients who got cardiac imaging stress tests before low-risk outpatient 5% of 249
5%
surgery. patients
Outpatients with brain CT scans who got a sinus CT scan at the same time. 3% of 628
3%
(Simultaneous use of brain and sinus computed tomography) patients

What are we doing to improve:

UC Irvine Department of Radiology is committed to providing efficient use of imaging procedures in our hospital outpatient departments. We
work continuously to reduce unnecessary exposure of our patients to contrast materials and/or radiation. Our improvement plans include
constant monitoring of compliance with evidence-based practice guidelines to protect patient safety and to avoid imaging tests that patients may
not need. We also monitor ordering patterns and collaborate with our medical specialties and departments to improve the ordering practices
among referring physicians.

National average Data Source:

Based on the national average from the Centers for Medicare & Medicaid Services (CMS ) Outpatient Quality Report.
Timeliness of Care
UC IRVINE MEDICAL CENTER
MEASURE DESCRIPTION (January 2015 – December 2015) NATIONAL AVERAGE
Lower is Better Higher is Better

Door-to-diagnostic evaluation by a qualified medical professional in 31 minutes 27 minutes

the ED

Median time to ECG 9 minutes 7 minutes

Median time to pain management for long bone fracture in the ED 67 minutes 52 minutes

Percentage of patients who left ED before being seen 3% 2%

Head CT scan results for acute ischemic or
hemorrhagic stroke patients who received head CT or 100% 70%
MRI scan interpretation within 45 minutes of ED arrival
Median time from ED arrival to provider contact for ED patients 31 Minutes 27 Minutes

What are we doing to improve:

UC Irvine Health Emergency Department is committed to providing comprehensive care and services for the ill and injured presenting for
services. Patient care is directed to the recognition, stabilization, evaluation, treatment, and disposition of patients in response to acute and episodic
illness and injury. We strive to provide excellent care during treatment while improving our customer service and the patient experience. Our
improvement plans include keeping patients informed about their care throughout their journey in the ED; reducing wait time for care, and the time to
see a physician. The nursing staff provides a bedside introduction to keep patient’s informed of their plan of care. Daily leadership rounds are conducted
with and extensive shift-change communications among clinical staff.

National average Data Source:

Based on the national average from the Centers for Medicare & Medicaid Services (CMS ) Inpatient Quality Report.
Stroke
UC IRVINE MEDICAL CENTER
MEASURE DESCRIPTION (January 2016 – December 2016) NATIONAL AVERAGE
Lower is Better Higher is Better

Thrombolytic therapy: Acute ischemic stroke patients who arrive at this hospital
within 2 hours of time last known well and for whom IV t-PA was initiated at this 92% 88%
hospital within 3 hours of time last known well.

What are we doing to improve:

UC Irvine Comprehensive Stroke & Cerebrovascular Center is dedicated to achieving the highest outcomes. We work continuously to improve the
care and treatment of our stroke patients. Our improvement plans include constant monitoring of compliance with stroke clinical practice guidelines
from the American Stroke Association. An example of an improvement plan is providing stroke education including personal risk factors for stroke
on discharge instructions. This ensures all stroke patients receive this important information before they are discharged.

National average Data Source:

Based on the national average from Centers for Medicare & Medicaid Services (CMS ) Inpatient Quality Report.
Venous Thromboembolism (VTE) Prevention
UC IRVINE MEDICAL CENTER
MEASURE DESCRIPTION (January 2016 – December 2016) NATIONAL AVERAGE
Lower is Better Higher is Better

Venous thromboembolism discharge instructions: Patients diagnosed with

confirmed VTE who are discharged to home, home care, court/law enforcement or 100% 93%
home hospice care on warfarin with appropriate written discharge instructions
Incidence of potentially preventable venous thromboembolism: Patients
diagnosed with confirmed VTE during hospitalization (not present at admission)
0% 2%
who did not receive VTE prophylaxis between hospital admission and day before
the VTE diagnostic testing order date.

What are we doing to improve:

We continue to have 100% compliance on all venous thromboembolism (VTE) core measures, except VTE‐1: VTE prophylaxis within 24 hours of arrival.
This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the
day after hospital admission or surgery. The MeasureVention report was developed by the Anticoagulation Steering Committee to provide a daily
assessment of all hospital inpatients of their VTE risk and prevention orders. The Nursing staff and physicians monitor this report to assure all inpatients
have the appropriate VTE prevention for their current health condition. MeasureVention reports are monitored for patients that are at moderate to high
risk and have no orders for mechanical or pharmacological prophylaxis; if there are any inconsistencies the physicians and nursing staff are contacted to
provide the appropriate VTE prevention. For patients that are moderate to high risk and only receiving mechanical prophylaxis—sequential compression
devices (SCDs), the inpatients are audited to assure they are receiving administration and documentation of SCDs.

National average Data Source:

Based on the national average from the Centers for Medicare & Medicaid Services (CMS ) Inpatient Quality Report.
Pregnancy and Delivery Care
UC IRVINE MEDICAL CENTER
MEASURE DESCRIPTION (January 2016 – December 2016) STATE AVERAGE

Lower is Better Higher is Better

Elective delivery: Induced births and cesareans before labor among

0% 2%
uncomplicated 37- and 38-week gestations.
Cesarean section: Cesareans among live births that are 1) singleton; 2) vertex; 3)
lacking "early onset delivery" ICD9 code; 4) > 37 weeks GA; 5) nulliparous 26% 27%
women.
Antenatal steroids: Patients at risk of preterm delivery at 24 weeks to 32 weeks
100% 100%
gestation receiving antenatal steroids prior to delivering preterm newborns.

What are we doing to improve:

UC Irvine Medical Center is committed to providing the safest and highest quality care possible to patients. Our improvement plans include
constant monitoring of compliance with evidence-based practice guidelines for perinatal care. UC Irvine Health does not perform deliveries
before 39 weeks gestation without indicating reason. UC Irvine Health also provides education for all community hospitals on the use and timing
of administration of antenatal steroids (betamethasone) to be given to all babies less than 34 weeks. This allows for improvement in lung
recruitment on high-risk babies. These processes sustain and help us improve upon our above-national-average performance.
California average Data Source:
Based on California Maternal Quality Care Collaborative Outcome Report
Immunization
UC IRVINE MEDICAL CENTER
MEASURE DESCRIPTION (January 2016 – December 2016) NATIONAL AVERAGE

Lower is Better Higher is Better

Patient influenza immunization 100% 94%

Healthcare personnel influenza vaccination 100% 84.0%

What are we doing to improve:

UC Irvine Medical Center is committed to standard influenza vaccination practice guidelines to prevent influenza virus infection and its potentially
severe complications. Our current rate for immunization is higher than the national average, however we are striving for further improvement to
reach 100%. Phone calls are made daily by Quality and Patient Safety to nurses on hospital units reminding them to vaccinate patients before
discharge or to document patient refusal. Several improvements were also made to the nurse screening tools in the electronic medical records,
allowing for accurate assessment of vaccine candidacy. Our Occupational Health clinic continues to improve accessibility to flu vaccination for
employees.

National average Data Source:

Based on the national average from Centers for Medicare & Medicaid Services (CMS ) Inpatient Quality Report.
Patient Safety Indicators
UC IRVINE MEDICAL CENTER
(February 2016 – January 2017) TARGET
MEASURE DESCRIPTION
(Vizient Risk Adjusted O/E Ratio)
Lower is Better Higher is Better

PSI-4 Death among surgical inpatients with serious treatable complications 1.03 1.104

PSI-12 Post-operative pulmonary embolism (PE) or deep vein thrombosis (DVT) 1.22 1.327

PSI-14 Postoperative wound dehiscence 0.00 0.307

PSI-15 Accidental puncture or laceration 0.38 0.548

PSI-90 Complication / patient safety for selected indicators (composite) 0.90 0.97

What are we doing to improve:

UC Irvine Medical Center is dedicated to achieving the highest outcomes and working continuously to improve the quality of patient care and patient
safety. We are committed to the standard of the government’s Agency for Healthcare Research and Quality (AHRQ) patient safety indicator guidelines
and evidence-based practices. Each patient safety indicator (PSI) case is thoroughly reviewed by different levels of the organization. Cases are
reviewed by a Quality and Patient Safety physician/ nurse team, and by the Critical Events Management Team in order to identify opportunities for
improvement. More specifically, all PSI 04 cases are reviewed by the Perioperative Committee and PSI 12 cases by the Anticoagulation Steering
Committee to further ensure there are no gaps in care.

Target Source:
Based on the outcome performance benchmarking data from all Academic Medical Centers in the Vizient Clinical Database.
Risk Adjusted Mortality
UC IRVINE MEDICAL CENTER
TARGET
MEASURE DESCRIPTION (February 2016 – January 2017)
(Risk Adjusted Mortality Ratio)
Lower is Better Higher is Better

Heart failure mortality ratio 0.34 0.92

Pneumonia mortality ratio 0.59 0.85

Stroke mortality ratio 1.01 0.96

Hospital-wide mortality ratio 0.93 0.92

What are we doing to improve:

Improving patient survival and reducing in-hospital mortality are at the core of UC Irvine Medical Center’s mission to provide the highest quality and
comprehensive healthcare to our patients. Every death at our hospital is reviewed to identify patient-safety issues, including system and process issues
that can be prevented or improved. Palliative care is always available to help improve the quality of life for our patients and their family members when
facing life-threatening conditions. A ratio of less than or equal to 1.0 is favorable and means that fewer patients died than expected based on the
performance of other teaching academic hospitals.

Target Source:
Based on the outcome performance benchmarking data from all Academic Medical Centers in the Vizient Clinical Database.
Readmission within 30 Days
UC IRVINE MEDICAL CENTER
(January 2016– December 2016) TARGET
MEASURE DESCRIPTION
(% of 30-Day Readmissions)
Lower is Better Higher is Better

Heart attack readmission within 30 days: Percent of eligible patients readmitted to

11% 8%
inpatient care within 30 days from the same discharged hospital.

Heart failure readmission within 30 days: Percent of eligible patients readmitted to

12% 16%
inpatient care within 30 days from the same discharged hospital.

Pneumonia readmission within 30 days: Percent of eligible patients readmitted to

11% 13%
inpatient care within 30 days from the same discharged hospital.

Chronic obstructive pulmonary disease readmission within 30 days: Percent of eligible

7% 11%
patients readmitted to inpatient care within 30 days from the same discharged hospital.

Stroke readmission within 30 days: Percent of eligible patients readmitted to inpatient

5% 13%
care within 30 days from the same discharged hospital.

Hospital-wide readmission within 30 days: Percent of eligible patients readmitted to

10% 11%
inpatient care within 30 days from the same discharged hospital.

What are we doing to improve:

Reducing and preventing 30-day inpatient re-hospitalization are at the core of UC Irvine Medical Center’s mission to provide the highest quality and
comprehensive health-care to our patients. UC Irvine Health has implemented the Transitional Care Management (TCM) program to support quality care and
optimize resource utilization for selected high-risk patients for readmission as they transition across the care continuum. We also work closely with skilled nursing
facilities to prevent avoidable re-hospitalization. Through our Readmission Task Force, we have been able to use technology and data to identify the high-risk
patients for hospital readmission while they are still in the hospital for early intervention and prevention.

Target Source:
Based on the outcome performance benchmarking data from all Academic Medical Centers in the Vizient Clinical Database.
Healthcare-associated Infections
UC IRVINE MEDICAL CENTER
MEASURE DESCRIPTION (January 2016-December 2016) NATIONAL AVERAGE
(Standardized Infection Ratio)
Lower is Better Higher is Better
Central line-associated bloodstream infections (CLABSI) 0.295 0.941
Central line-associated bloodstream infections (CLABSI) ICU only 0.295 0.485

Catheter-associated urinary tract infections (CAUTI) 0.501 0.983

Catheter-associated urinary tract infections (CAUTI) ICU only 0.503 0.864

SSI- Colon surgery 0.735 0.989
SSI- Abdominal hysterectomy 1.285 0.990
Methicillin-resistant Staphylococcus aureus (MRSA) blood laboratory-identified
0.891 1.351
events (bloodstream infections)
Clostridium difficile (C. diff) 0.949 0.997

What are we doing to improve:

SSI Colon/abdominal hysterectomy: Numerous interventions driven by the University of California Medical Center SSI Improvement Collaborative include focus on:
Implementing standard perioperative bundles (patient pre-op with chlorhexidine gluconate (CHG) bathing, patient education, intra-op aseptic technique monitoring,
post-op CHG bathing, patient education, transfer wound care order set for skilled nursing facilities), regular review of all outcomes with Department of Surgery Chair.
C. diff: Numerous interventions driven by a UC Irvine Medical Center Lean Six Sigma team include focus on : Hand hygiene, environmental cleaning, high-touch item
cleaning, appropriate use of isolation precautions, appropriate testing for clinical patients, antibiotic stewardship, improved clinical documentation.
CLABSI: UC Irvine Medical Center has an ongoing CLABSI performance improvement team that supports best practices for insertion, maintenance and discontinuation.
This team developed a novel central line insertion site assessment (CLISA) scoring tool that focuses on identifying at risk lines, currently implemented in our inpatient
care units and outpatient infusion centers. Regular reviews of CLABSI cases are conducted during the reporting quarter.
CAUTI: UC Irvine Medical Center has an ongoing CAUTI performance improvement team focusing on best practices for insertion, maintenance and early removal of foley
catheters, with an emphasis on utilizing noninvasive urinary devices. Review for best practices are conducted on all known cases.
MRSA: UC Irvine Medical Center is participating in a new public health/CDC initiative in Orange County called SHIELD OC. This is a regional intervention using antiseptic
National
soaps foraverage
bathingData Source: to cleanse the nose in an effort to reduce MDROs in health care settings across the entire community. UC Irvine Health has instituted
and iodophor
Based on the national average from Centers for Medicare & Medicaid Services (CMS ) Hospital Compare Preview Report.
daily housewide bathing of all inpatients with chlorhexidine soap and decolonization of all ICU patients. UC Irvine Health is trialing WHONET, a global microbial tracking
surveillance program for infectious diseases that assists in effective cluster identification, containment, and control of MDROs such as MRSA.
National average Data Source:
Based on the national average from the Centers for Medicare & Medicaid Services (CMS ) Inpatient Quality Report.