Loyola has long been committed to the quality of care and safety of its patients. We also believe in sharing quality information with the public and in participating in national quality improvement programs such as the federal Centers for Medicare and Medicaid Services Hospital Quality Alliance, the National Quality Forum, which is leading the development of a national quality measurement reporting system, and the University HealthSystem Consortium, an organization of major academic medical centers working to improve many aspects of health care.

Loyola prioritizes and coordinates performance improvement activities across the entire institution through its Center for Clinical Effectiveness (CCE). The CCE implements state-of-the-art quality and safety improvement tools, and communicates results of performance improvement work both within Loyola and to consumer, health-care and academic audiences. Loyola dedicates $1 million of its annual budget to fund the work of the CCE.

Loyola University Health System (Loyola) is committed to safe, high quality health care. We believe it is our responsibility to publicly share the results of our care data in a scientifically responsible manner in order to help you make better decisions regarding your health care. We share information that the government, regulatory agencies and employers find helpful in understanding how hospitals are doing.

With so many sources for health-care information and measures, it's important to understand what to look for when reviewing such data.

• Most importantly, be sure the rankings are open to peer review and are based on scientifically valid measures, because many are not.
• Choose a source that is open about its methodology; find out exactly what they are measuring, the data sources and how old the data is.
• Listings based on the reputation or popularity of hospitals and/or physicians are not using scientific measures of quality nor do they have scientific validity. Still others use self-reported data without any form of validation.
• If it is Medicare-only data, keep in mind that this involves a specific age group, people over the age of 65. That information may not be applicable to younger adults and children. Does the ranking system use billing data only or is it supplemented with clinical data? In addition, results can be quite different unless they appropriately take into account how sick patients are and what other serious medical conditions are present – this is a very difficult and complex science.
• The source of the data needs to be a credible one. The firm that does the rankings should not require a hospital or physician to pay a fee in order to be ranked. Additionally, you should not have to pay for this type of information. It is available from credible, quality sources for free.

National Standards

Among the organizations that conduct premier quality collection and reporting are:

• National Quality Forum (NQF), a public/private partnership charged with the task of creating a national quality measurement and reporting system
• University HealthSystem Consortium, an organization of major academic medical centers working to improve many aspects of health care
• The Joint Commission, an independent, not-for-profit organization that accredits and certifies health-care organizations and programs nationwide for quality and performance standards
• The U.S. Department of Health & Human Services' Centers for Medicare and Medicaid Services (CMS), a government agency that promotes quality care for its participants

Both the Joint Commission and CMS use NQF measures.

Loyola voluntarily participates in the CMS Hospital Quality Alliance, which is collecting and reporting data on the first few key measures of hospital care that are scientifically validated (heart attack care, heart failure care, pneumonia care).

Loyola compares very favorably in nearly all of the measurements. We are aware that our scores in a few areas are not optimal, and we have a team of experienced physicians, nurses and administrators actively working to address these issues. Loyola also is working to improve many other areas of care that are not yet part of the CMS alliance including: surgical infection rates, aspects of intensive care unit care and beta blockers to reduce heart attacks after surgery.