Quality & Safety

UMHS Quality and Safety: Committed to Excellence

At the University of Michigan Health System, our goal is to become the national leader in health care quality and safety. For many measures, we're already there. For other measures, we have concrete plans to improve.

We are working hard to improve our rates of hospital-acquired infections, including avoiding MRSA infections, central-line infections, C difficile infections, cathether-urinary tract infections and surgical site infections. We have a robust surveillance system that allows us to identify infections better, and we actively go looking for certain infections through surgical case reviews.

Like most healthcare institutions, we are striving to improve, but remain confident we will continue to reduce infections and improve our patient safety.

Our efforts have already resulted in improvements:

  • Brandon Neonatal ICU has gone over a year without a Central Line Bloodstream infection. (UM is part of the Vermont Oxford Network for Neonatal ICUS)
  • The Trauma Burn ICU decreased its Catheter-Associated UTI rate by 46% from 2013 to 2014 (UM is part of the MHA on the CUSP Collaborative)
  • We had 50 fewer cases of C.difficile in 2014 vs. 2013, and 2015 is on track as well with lower numbers (UM is part of the MDCH C.diff Collaborative)
  • Our total knee arthroplasty SSI rate decreased 46% from 2013 to 2014 (1.7% to 0.7%) (UM is part of the MARCQI Collaborative – Michigan Arthroplasty CQI)
  • Our hysterectomy SSI rate decreased 59% from 2013 to 2014 (UM is part of the MSQC – Michigan Surgical Quality Collaborative)
  • Our pediatric cardiac SSI rate decreased by 69% from 2013 to 2014 (UM is part of the Solutions for Patient Safety Collaborative)
  • Most of our Adult ICUS have shown improvements in their ventilator pneumonia or infectious ventilator associated complications rates in 2015 vs. 2014 (UM is part of the MHA Keystone ICU Collaborative)
  • Our MRSA Bacteremia rates have been trending down from 2013-2015 (UM is part of the MDCH MRSA SHARP Collaborative)

This site shows where we're doing great and where we can perform even better. The site also offers information about quality care, quality measures, and what quality really means to the most important people in our community: you - our patients and families. While quality reports from other sites may be a year old or more, the reports on our website show the most up-to-date measures of quality and safety at the University of Michigan Health System.

Explore these pages to learn more about how we engage in quality and safety 24 hours a day, seven days a week!

What are quality and safety in health care?

The federal Agency for Healthcare Research and Quality (AHRQ) defines quality health care as "doing the right thing, at the right time, for the right person, and having the best possible result." Patient safety - the act of doing no harm - underlies all aspects of quality health care.

Clinical quality may mean measuring:

  • the number of patients who experience infections following surgery
  • the number of patients readmitted to a hospital after their discharge due to complications
  • adherence to evidence-based practices (treatments and procedures that are based on sound scientific knowledge)

Quality can also be measured by looking at aspects of the patient experience delivering patient care such as:

  • timely access to care
  • effectiveness of care
  • patient safety and medical errors
  • patient satisfaction
  • customer service

Several groups measure quality of care, which one can use to compare our results to those of other organizations. For example:

  • The Greater Detroit Area Health Council measures the care provided by hospitals and physicians in Southeast Michigan on My Care Compare.
  • The federal government's Centers for Medicare & Medicare Services measures hospital quality on Hospital Compare, and
    The Joint Commission measures quality and safety as it conducts its accreditation reviews.
  • Media like USNews & World Report provide consumers with health care quality reports.

How do we measure quality?

At the University of Michigan Health System, we evaluate the quality of the care we deliver by measuring whether it is effective, timely, safe and responds to our patients’ preferences and needs.

For this website, we chose to display measures that are valid and meaningful and reflect the quality of care in both the inpatient (hospital) and outpatient settings. For most measures, we are able to compare our performance to that of other hospitals and physician groups. In many cases, our performance is better, in some cases it is not. Our goal is to demonstrate our commitment to delivering high quality of care and to continuous improvement by being open and honest and "transparent" about our performance.

In this website, we report several types of quality of care measures. Some measure whether we are providing the right treatments and procedures. These are called process measures. They are used to assess the degree to which we (and other health care providers) use best practices when delivering care to patients. Here’s an example:

  • The percentage of patients with a heart attack who receive aspirin upon arrival at the hospital. Scientific evidence shows that heart attack patients who receive aspirin upon arrival have a better chance of survival (better outcomes).

Others measure outcomes, or the success of treatments and procedures.

Outcomes may include patient survival rates or infection rates.

Outcome measures are the most difficult to produce and interpret because they are influenced by many factors, including the patient's health condition. For example, an 85 year-old patient with chronic lung disease and pneumonia will not have the same chance of survival as an otherwise healthy 40 year-old patient with pneumonia.

Because the risk of death or of complications like infections differs between patients, we try to compare our outcomes to those of similar types of patients. However, this may not be possible. For some outcomes, the comparison statistic can be "adjusted" to reflect a similar patient population. But, unfortunately, these adjustment methods are not perfect. As a consequence, if we treat a "sicker" patient population, our rates can be higher. Because of the difficulty in obtaining good comparison or benchmark data, one should use the outcome measurement results with caution.

Here are examples of outcome measures:

  • Survival rate for patients who arrive at the hospital with a heart attack
  • Rate of wound infections after surgery

How should you use these quality and safety reports?

Because you play a role in maintaining your own health care, you can use these reports to find out:

  • how well our doctors provide care
  • how we do on the things that health care experts have determined are important for measuring health care quality and safety
  • how we stack up against other organizations that do similar work.

Keep in mind:

  • The quality data on some other quality sites may be a year old and may not reflect our current quality improvement programs. In many cases, this site will contain more up-to-date data.
  • Some of the more severely ill patients in Southeast Michigan - and from around the country - come to the University of Michigan Health System for their care because of our experience in effectively managing their condition.