Quality Measures

It is easy to make claims about providing quality care.
But what does quality care really mean? At Middlesex Health, we believe in providing evidence, such as outside expert reviews and self-evaluation, to support any claims of excellence. 

What are quality measures in health care?
The goal of health care is simple: to help every patient be as safe and healthy as possible. Achieving this goal can be more complicated. It requires that each and every patient, at the very least:

  • Has access to timely care when they need it
  • Has doctors, nurses and other providers who follow evidence-based guidelines
  • Can go to health care facilities that are clean and well-kept
  • Is treated with dignity, respect and compassion

Quality measures are tools that help health systems determine if they are meeting these standards for their patients.

Does Middlesex Health use quality measures?
Yes! In fact, Middlesex was one of the first health systems in Connecticut to voluntarily participate in major quality programs facilitated by government and industry organizations. 

Over time, these programs have grown in number and in sophistication. Today, there are multiple websites on which consumers can access a wide range of data on individual health systems, and compare those health systems to others.

Quality Reports for Middlesex Health

To find information on Middlesex Health, please click on any of the programs below. Under each program, you will find a link to their report, as well as details about how that organization measures quality of care.

Hospital Compare provides information for the public about how hospitals perform in delivering recommended care to patients. This tool allows you to look at how multiple hospitals compare to each other.

Middlesex Hospital's Hospital Compare Report

 More About CMS Hospital Compare

CMS carefully monitors the quality, safety, and experience of patient care in hospitals across the nation. All hospitals are required to abstract specific data from patient records for a variety of conditions and in accordance with a dictionary that ensures the subsequent reports can be used for fair comparisons of one hospital to another. CMS applies a risk adjustment methodology so that comparisons are based on the severity of each patient’s condition. The major categories measured are Clinical Care, Safety, Patient Experience (Satisfaction Survey Results), and Cost (average cost per Medicare beneficiary).

The following is a list of the measures used and reported by CMS:

  • Quality
    • Death within 30 days of inpatient admission for acute myocardial infarction (AMI)
    • Death within 30 days of inpatient admission for Heart Failure (HF)
    • Death within 30 days of inpatient admission for Pneumonia
    • Complications following total hip and total knee replacements
  • Safety
    • Clostridium Difficile Infections (C-Diff)
    • Catheter Associated Urinary Tract Infections (CAUTI)
    • Central Line Associated Bloodstream Infections (CLABSI)
    • Surgical Site Infections for colon surgery and hysterectomy
    • Elective delivery prior to 39 weeks of gestation
  • Efficiency
    • Average cost per medicare beneficiary
  • Patient Experience 
    • Patient Satisfaction Scores as measured by the Hospital Consumer Assessment of Providers and System
    • Measures satisfaction of patients with communication, nursing, physicians,cleanliness,medication, discharge, and overall rating of care.
  • Readmissions
    • Readmission within 30 days of inpatient admission for acute myocardial infarction (AMI)
    • Readmission within 30 days of inpatient admission for Heart Failure (HF)
    • Readmission within 30 days of inpatient admission for Pneumonia
    • Readmission within 30 days of inpatient admission for Chronic Obstructive Pulmonary Disease (COPD)
  • Patient Safety Index (PSI 90)
    • CMS additionally collects information of a multitude of hospital acquired conditions, hospital acquired infections, and surgical site infections and combines them into a composite score titled PSI 90.

There are over 80 separate measures that are tracked by CMS. It is important to note that Middlesex Hospital also tracks each of the measures internally and uses the information to identify any areas that warrant further investigation and improvement initiatives. Time periods for each measure differ, and the information is up to four years old.

Healthgrades® is a U.S. company that provides information about hospitals, physicians and other health care providers. Each year, they designate top performing health care institutions.

Middlesex Health's Healthgrades® Ranking Report

More About Healthgrades® Reporting

Data sources for Healthgrades® rankings and various distinctions are compiled from CMS, MEDPAR and Hospital Compare Data. The data include information on mortality outcomes, complications, clinical excellence, patient safety, patient experience and specialty procedures/care excellence.

The 'America’s Best Hospitals' distinction is awarded on the basis of clinical outcomes for 32 conditions and procedures. The top 1%, 2%, and 5% of hospitals in the nation are recognized for demonstrating consistent and overall high quality performance year over year.

Middlesex Health has earned many Hospital Quality and Specialty Clinical Quality Awards over the years. In 2020, Middlesex earned more than 25 awards, including distinction as one of Healthgrades® America's 100 Best HospitalsTM. Other awards include recognition for outstanding patient experience, stroke care, pulmonary care, critical care, gastrointestinal care and more.

All Middlesex Health Healthgrades® 2020 Designations

Middlesex Hospital voluntarily participates in NSQIP, a nationally validated, risk adjusted surgical outcomes program with a goal of measuring and improving surgical care. Although NSQIP does not publish actual report cards to the public, Middlesex was notified that for 2019, we received exemplar status for achieving low rates of morbidity and complications for all surgical procedures, including low rates of postoperative infections.

The Joint Commission on the Accreditation of Healthcare (TJC) is an organization that provides hospitals with an opportunity to be voluntarily evaluated for Accreditation. Accreditation is an intensive review that deems a hospital as meeting all standards of excellence in patient care.

The TJC is authorized by CMS to provide deemed status for financial reimbursement and is also a designation that serves as an assurance to the public that care is safe.

TJC Quality Check site is available to the public. We encourage you to visit this site to see the Quality Report for Middlesex.

Middlesex Health's The Joint Commission Quality Report

Leapfrog was established in 2000 by a large consortium of employers and purchasers of healthcare. It is a national nonprofit organization with the mission of triggering giant leaps forward in the safety, quality, and affordability of U.S. health care by using transparency to support informed healthcare decisions and promote high value care.

Middlesex Health's Leapfrog Report

More About Leapfrog

Based onLeapfrog’s methodology, in order to achieve full credit for all safety and quality activities, a hospital must commit to joining Leapfrog and filling out an extensive application that requires continuous resourcing by health care employees and electronic health record systems. Leapfrog does publish reports of those who apply and those who do not apply. Generally, unless a hospital applies, the final score will be less than optimal.

Middlesex was, historically, a Leapfrog Hospital, achieving scores of A. Our scores have fluctuated between B and C when not applying and an A one year without replying. We have made the decision, effective August 2020, to once again complete an application. We will look forward to ultimately achieving a consistent A score on an annual basis.

For Spring 2020, without providing data to achieve a higher score, we were assigned a Leapfrog grade of C. Even without filling out an application, we were only 0.01 points from a score of B.