BayCare Clinic develops and measures a host of quality indicators for each of the specialties that we serve. Quality indicators fall into one of two categories: process or outcome.
Process quality indicators measure a BayCare health professional's adherence to a process that is believed to be of benefit to the patient.
Outcome quality indicators measure the actual outcome of the patient's treatment plan, which may include objective measures of result as well as patient satisfaction with the services or results.
Below you will find a list of BayCare Clinic's quality indicators, projects, and achievements listed by specialty.
All Specialties
Advance Care Planning: BayCare Clinic recognizes the right of patient's to fully participate in health care decision making. We offer patients the paperwork, and access to assistance, to complete advance care plans.
BayCare Clinic has implemented a Patient Feedback Register. This computerized database allows BayCare Clinic staff to enter feedback, both positive and negative, received from patients and their families. Feedback from patients can be verbal, in writing, or sent over the internet. Evaluating these comments in detail allows us to benefit from each patient’s experience. Managers and staff can easily review comments to identify best practices, as well as identify opportunities to improve clinical care, communication with patients, or business practices involved in the total healthcare experience.
Medication Management: This initiative strives to ensure patient safety and optimal health care management. The process of reviewing and documenting current medications with each patient visit helps both patients and health care providers to:
Patient Education Tools: Prior to undergoing a procedure that has associated risks, physicians work with patients to make knowledgeable choices. In an effort to improve each patient’s ability to participate fully in making informed decisions, BayCare Clinic is developing procedure specific patient education tools. These tools, written in collaboration with the physician, describe what will happen during the procedure, what it will look and feel like, as well as what to expect during recovery. Risks, benefits and alternatives to the procedure are also listed. BayCare Clinic recognizes that healthcare visits are often stressful times. We hope that by providing these easy-to-read materials, patients can review details when they are best able to think about options, and plan their care.
Anesthesia
Spinal Headache Post Labor Epidural: This measure helped to identity the best practice in the treatment and prevention of spinal headaches after labor.
Fertility Clinic Sedation: The study of quality indicators during this procedure led to the development of a sedation protocol which improved patient comfort and reduced the incidence of post-procedure nausea.
Laparaoscopic Cholesystectomy Patient Outcome Measurement: Standardization of best practice resulting in decreased recovery time.
Prevention of anesthesia related surgical procedure delays or case cancellations: This process outcome analyzes any delay or cancellation in order to identity factors which will improve the process for future patients.
Post operative pain management following Total Knee Replacement: The Anesthesia department evaluated pain management options to identify best practice for managing pain following this surgery.
Cardiology
Standardization of physician order sets to best practice protocols for Acute Myocardial Infarction (AMI) and Congestive Heart Failure (CHF).
Francis G. Wolf, MD, and William Witmer, MD, received recognition from the National Committee for Quality Assurance (NCQA--
for further information please visit www.ncqa.org/hsrp) and the American Heart Association/American Stroke Association's (AHA/ASA) Heart/Stroke Recognition Program. This recognition is awarded to Dr. Wolf and Dr. Witmer for providing quality care to their patients with cardiovascular disease or who have had a stroke.
The Heart/Stroke Recognition Program was designed to improve the quality of care that patients with cardiovascular disease or who have had a stroke receive by recognizing physicians who deliver quality cardiovascular and stroke care, and by motivating other physicians to document and improve their delivery of cardiovascular and stroke care. To receive recognition, which is valid for three years, Dr. Wolf and Dr. Witmer submitted data that demonstrates performance that meets the Program’s key cardiovascular and stroke care measures. These measures include blood pressure and cholesterol control, among others. When people with cardiovascular disease or who have had a stroke receive quality care as outlined by these measures, they are less likely to suffer additional complications, such as a second heart attack or stroke.
Dr. Mathias, Dr. Witmer and Dr. Wolf have each been awarded ‘star status’ by United Health Care, one of the largest national commercial insurance carriers. Physicians are eligible to earn a quality star and efficiency star. The quality star indicates that these physicians adhere to “nationally recognized standards based on expert physician advice”. The efficiency star is awarded to physicians based on how efficiently they manage an entire episode of care for each patient. The efficiency star evaluates whether physicians perform unnecessary tests, manage medications effectively, make appropriate referrals, etc. Each of the BayCare Clinic cardiologists earned both the quality and efficiency stars.
In addition the Cardiology physicians of BayCare Clinic are crucial participants in managing the care of patients who have had heart attacks and admit to Aurora BayCare Medical Center. The Centers for Medicare and Medicaid Services publicizes data about how well hospitals care for patients who experience heart attacks. At the www.hospitalcompare.hhs.gov website the public can view hospital results. ABMC is among the top 10% of hospitals in the nation, as rated by the Centers for Medicare and Medicaid Services, in providing care to patients with heart attack.
Cardiothoracic Surgery
Mortality; Length of Stay; Cost
BayCare Clinic Cardiothoracic surgeon, Dr. Alex Roitstein, has consistently volunteered to submit data on processes and results related to cardiothoracic surgery to the Centers for Medicare and Medicaid Services. By participating in these programs Dr. Roitstein demonstrates his commitment to assuring the public will be able to access information that can help them select the doctor best suited to meet their needs. Dr. Roitstein has also earned the quality and efficiency star rating from United Health Care.
Dr. Roitstein actively contributes data to the Society for Thoracic Surgeons for review of quality as well as advancement of the field for the benefit of all patients.
Ear, Nose & Throat
The otolaryngologists are participating in a study to evaluate the impact of ear tube placement on the quality of life for patients and their families.
In addition, the Ear, Nose & Throat physicians volunteered, and are actively participating in a Medicare Program evaluating the quality of care being provided in the outpatient setting, the “Physician Quality Reporting Initiative”.
Emergency Physicians
American College of Surgeons (ACS) Level II Trauma Certification.
The Emergency Department physicians provide initial services to many patients for heart attack, congestive heart failure, and pneumonia. At the www.hospitalcompare.hhs.gov website the public can view hospital ratings in providing appropriate care to these patients. For heart attack and pneumonia ABMC ranks amongst the top 10% of hospitals in the nation. For congestive heart failure, ABMC ranks amongst the top 20%.
The Emergency physicians have elected to participate in Medicare’s nationwide voluntary reporting program that measures the care provided to patients with pneumonia, stroke, heart attack, chest pain and syncope while in the Emergency Department.
General & Vascular Surgery
Carotid Endarterectomy: Reduce complication rate based on the development of best practice protocols.
American College of Surgeons (ACS) Level II Trauma Certification.
Green Bay Eye Clinic
Care of Patient undergoing Cataract Surgery: Establishment of evidence-based practice guidelines.
The ophthalmologists and optometrist at Green Bay Eye Clinic have volunteered, and are actively participating in a Medicare Program evaluating the quality of care being provided in the outpatient setting, the “Physician Quality Reporting Initiative”.
Neurological Surgeons
Anterior Cervical Fusions : Establishment of evidence based best practice guidelines.
The BayCare Clinic Neurosurgeons are gathering information about the impact of spinal surgery on the patient’s ability to perform activities of daily living.
American College of Surgeons (ACS) Level II Trauma Certification.
Spine: Morbidity, Mortality, Length of Stay, Cost.
Stroke: Morbidity, Mortality, Length of Stay, Cost.
Each of the BayCare Clinic Neurosurgeons have earned the United Health Care quality star.
Neuropsychology
Credentialed ImPACT Consultant for Concussion Management.
The neuropsychologist group is looking to evaluate access to their services – determining if patients are able to get appointments within a timeframe acceptable to them, and appropriate for their condition. This group of specially trained psychologists performs and provides expert testing that helps referring physicians plan appropriate care. The BayCare neuropsychologists have a formalized process to survey referring providers. Referring providers are able to provide information that ensures the neuropsychology group is providing the type and quality of information that meets both the patient and the referring provider’s needs.
Orthopaedic Surgery & Sports Medicine
Dr. Hennigan, Dr. Henry, Dr. Limoni, and Dr. Schnaubelt and have each been awarded both the quality and efficiency stars by United Health Care.
The Orthopedic surgeon group submits data on patients who undergo hip or knee replacement to the Centers for Medicare and Medicaid Services. Consumers can view results for Aurora BayCare Medical Center, for these types of surgery, at www.hospitalcompare.hhs.gov.
Rotator Cuff Surgery: Study was completed to evaluate the physician and clinic services provided to patients undergoing rotator cuff repair.
Total Knee Replacement: Study was completed to evaluate the physician and inpatient services provided to patients undergoing knee replacement. This study specifically focused on pain management, meeting patient’s discharge destination goals, and reducing the risk of surgical complications.
The Orthopedic surgeons have volunteered, and are actively participating in a Medicare Program evaluating the quality of care being provided in the outpatient setting, the “Physician Quality Reporting Initiative”
Interventional Pain Management
These specialty physicians are actively working toward achievement of the National Committee for Quality Assurance Recogntion for the care provided to patients with back pain.
Plastic Surgery
The physicians of this group participated in the national voluntary reporting initiative of the Centers for Medicare and Medicaid Services. This project is specifically looking at the care physician’s provide to patients with a current or past history of malignant melanoma.
The Plastic Surgeons are developing a measurement plan to evaluate patient satisfaction following breast surgery.
Pulmonary Medicine
The pulmonologist have volunteered, and are actively participating in a Medicare Program evaluating the quality of care being provided in the outpatient setting, the “Physician Quality Reporting Initiative”.
Radiology
Development of patient education tools to enhance patients' understanding of complex radiologic procedures.
The Radiology group submits information to Medicare’s “Physician Quality Reporting Initiative” to evaluate radiologist quality practices related to the diagnosis of stroke and the placement of central venous catheters.
Physical Medicine & Rehabilitation
These specialty physicians are actively working toward achievement of the National Committee for Quality Assurance Recogntion for the care provided to patients with back pain.
Urological Surgeons
Urinary Incontinence Rate after a Radical Prostatectomy
Stone Passage Rate/Percutaneous Nephrolithotomy (PCNL)
Incontinence Rate after Laser
Success Rate Ultrasound Post Ureteroscopy
The Urology physicians volunteered, and are actively participating in a Medicare Program evaluating the quality of care being provided in the outpatient setting, the “Physician Quality Reporting Initiative”.
CLIA Recertification
Timothy J. Kennedy, MD, FACS, is a Member of the Society for Pediatric Urology
