Frequently Asked Questions


How do we select quality measures for reporting?

We select measures which reflect high volume or high risk conditions that have well defined and accepted definitions for external comparison and internal improvement. We research current literature, seek input from physicians and employees to identify areas for improvement. Many of our measures have been chosen by Federal and state agencies and other health care experts as measurements of high quality medical care for certain conditions representing some of the most common and costly conditions that hospitals treat. By analyzing and reporting on a common set of measures, doctors and their patients can compare information easier and make informed decisions from reliable sources.


How do we use these measures to improve our care?

Measures provide the necessary feedback to ensure our efforts to improve our systems and processes are effective. We attempt to provide this data to those closest to our patients and who are in the best position to use them for improvement. Many of these measures are posted for our staff to see on the patient care units. We also share our quality measures with the medical staff and with our Board of Directors.


Why are your measures less than 100%?

One of the first steps in achieving 100% is to implement documentation systems to capture the required data. We may be providing the recommended care, but if we don’t document it in a very specific manner, we can’t count it. This often involves having physicians document why they do not recommend a certain practice based upon the patients condition. We also live in a dynamic world in which the evidence often changes faster than the definitions and measurement systems


Who oversees the quality of care?

Our Board of Directors oversees the quality of care for all Cottage Health System hospitals. They receive regular reports of our quality measures and improvement efforts. In addition, the Medical Staff leadership participates in our Quality and Patient Safety Committee and has delegated responsibility for patient care.