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Washington Hospital Participates in Nationwide Program to Improve Outpatient Care

March 25, 2014

As part of a longstanding commitment to quality, Washington Hospital measures and tracks many aspects of the patient care it provides. To continually improve performance, the Hospital regularly compares the data it collects to its previous record and against the performance of other hospitals in the region, state and nation.

Washington Hospital also reports the data it collects to the Centers for Medicare and Medicaid Services (CMS), the U.S. agency that helps administer the government's Medicare, Medicaid and Children's Health Insurance programs. One goal of CMS is to assist people on Medicare in making more informed decisions about their health care. The quality of care information submitted by hospitals across the country is available to the public on CMS' Hospital Compare Web site

"A quality measure converts medical information from patient records into a rate or time that allows facilities to assess their performance and consumers to compare how well patients are being cared for at their local hospitals," says CMS on its Web site,

The data collected by CMS is also part of its "pay for quality" Hospital Outpatient Quality Reporting Program, which provides hospitals with a financial incentive to report their quality of care measure data. CMS requires hospitals to meet certain administrative, data collection and submission, validation and publication requirements in the way it collects and reports the data. If those requirements are not met, the hospital receives a 2 percent reduction in its annual Medicare payment.

Updating the Board of Directors

Recently, Barbara Eusebio, R.N., Washington Hospital's Associate Administrator and Chief of Quality and Resource Management, updated the members of the Washington Township Health Care District Board of Directors on data reported to CMS about outpatient services. This includes laboratory testing, imaging services, outpatient surgery, and care in the Emergency Department. The data covered services provided during the current 2013-14 fiscal year.

"Through this data reporting program, CMS is working to help hospitals improve the process, structure, outcomes and efficiency of providing outpatient care," explained Eusebio. "One of the main priorities is making sure hospitals aren't providing unnecessary care."

Washington Hospital reports on 23 measures related to outpatient care. The data, which keeps patient names confidential, is abstracted from patient medical records.

The CMS program also tracks a number of Web-based indicators designed to measure the use of communications technology to improve care. For example, one measure assesses the ability of physicians to receive the results of lab tests electronically and clearly through their electronic health record system.

"With EPIC, Washington Hospital Healthcare System's electronic medical record, physicians who have the system in their offices are able to get test results quickly," stated Eusebio.

Last year, CMS added several new outpatient indicators to its outpatient program, and Washington Hospital is now reporting on these:
* Are outpatient surgery patients being given antibiotics within one hour after surgery?
* Are outpatient surgery patients being given the right antibiotic after surgery?
* Are patients being treated in the Emergency Department, from arrival to discharge, in a timely manner?

Performance results
In her report to the Board, Eusebio covered some examples of Washington HospitalÕs outpatient data from the current 2013-14 fiscal year:

In the last four years, the Hospital has further improved its administration of antibiotics to patients having outpatient surgery:
* The percentage of patients receiving an antibiotic at the right time has improved from 93 percent to 96 percent.
* The percentage of patients receiving the right type of antibiotic has increased from 93 percent to 99 percent.

Compared to other California hospitals, Washington Hospital is the same or better in the way it provides certain diagnostic imaging procedures:
* Follow-up with outpatients receiving mammography, ultrasound and MRI is 100 percent.
* The percentage of outpatients receiving CT scans of the abdomen or chest with and without contrast - referred to as Òdouble scanning" - is in line with other California hospitals.
* The percentage of outpatient receiving a stress test before having low risk surgery is well below the California average. CMS considers administering this test prior to low risk surgery to be unnecessary.
* The percentage of Emergency Department patients receiving CT scans of the brain and the sinuses is in line with other California hospitals. Administering both scans is considered unnecessary.

Eusebio reported that Washington Hospital will continue monitoring its performance on these and other measures tracked by CMS.

"We continue to evaluate the necessity of tests and follow-up procedures, according to CMS recommendations," explained Eusebio. "We also educate our providers about the appropriateness of tests and the risks and benefits involved."

Learn More About Our Quality Initiatives

To learn more about Washington Hospital's quality initiatives, visit To review the latest outpatient data collected by the Center for Medicare and Medicaid Services (CMS), go to