Questions & Answers

1. What is in the Quality Report?

Mountain View Hospital is displaying both clinical results and patient satisfaction results.

Clinical results are shown in percentages.  This is the percentage of patients who received the required components of "evidence based care" for their particular diagnosis.  The descriptions of our performance are compared to national recommended safe practices.

Ratings. We rate our performance as explained below:

• Indicators that are percentages or ratios. If national data are available for an indicator, we compare our performance to the national average. We use the national average for other Critical Access Hospitals our size when available. 
• Safe practices.  We give a subjective self-assessment of our progress.

2. How do you select the quality indicators and safe practices?

National organizations have endorsed lists of quality indicators and safe practices. We address every hospital item on each endorsed list that apply to hospitals our size and the services we provide; we do not select only certain items. All the indicators or safe practices have extensive research to support their use and are defined so that all use the same method for calculating the statistics.

Indicators and safe practices are not perfect, however. We do not agree that all the items we are reporting are valid assessments of important quality issues. Even for such items, however, we use the national definition and report our performance. This full reporting is our assurance to you that we are not selectively reporting only our strengths.

3. Does this Quality Report rate individual physicians?

No. We are publishing hospital data only.

4. Do you share this information with other hospitals?

Generally not. Not all hospitals publish this data.  While the hospitals of Cascade Health Care are all committed to public reporting of their quality data, we do not provide the same services, so we report different data.  Data for 21 of the indicators we report on can be found at Hospital Compare, however that data is usually 1-2 years old. Mountain View Hospital voluntarily submits the limited data requested for Hospital Compare, but the information we're displaying in this report is much more comprehensive and more up-to-date.

The Oregon Association of Hospitals and Health Systems publishes data about the charges and quality of Oregon hospitals. Mountain View Hospital is a strong supporter of this increasing "transparency" about hospital performance.

Average indicator performance for hospitals in Oregon and for the nation (U.S. ) is displayed, if available. Obviously, those averages do not represent the performance of any individual hospital.

5. Why is Mountain View   Hospital publishing its quality data?

We like what open reporting does for you. As a not-for-profit Critical Access Hospital and a community resource, we believe that you should know how we are performing. We want patients and families to have better information about the quality of healthcare.

We like what open reporting does for us. We have found that public reporting has helped us document our care more carefully, obtain more valid data, and give better patient care than we would have without public reporting.

We like what open reporting does for hospital care in general. We hope that our Quality Report will contribute to a better understanding of how to assess, report, and improve hospital quality. We welcome the chance to collaborate on better methods for making hospital quality data public.

6. What does "risk-adjusted" mean?

The risk of a complication or death varies by patient and by procedure. For example, an older surgical patient who has complicating illnesses such as kidney failure and diabetes is at greater risk of developing complications than a young, healthy patient is. Open heart surgery has a greater risk of a collapsed lung than knee surgery does.

Risk adjustment mathematically takes into account differences in patient and procedure risk factors, so that comparisons are more meaningful. Risk adjustment allows for comparison of actual performance with predicted performance, based on the average U.S. hospital. More details of risk adjustment are explained on the sites of the national organizations that endorsed these indicators.

7. If a hospital's performance is low, does that mean it provides bad care?

It's not that simple.

There are many possible reasons that performance on an indicator might be low. Here are a few:

• The hospital may provide care that is worse than the national average.
  About half the hospitals in the U.S. will be worse than average on any given indicator. No one wants to be worse than average, but even performance that is significantly worse than the national average may still be well within the range of good care.
• The hospital may do a better job than other hospitals of detecting and reporting infections or complications.
• The hospital may do a worse job than other hospitals of detecting and reporting risk factors, so the hospital is not getting full credit for the complexity of its cases.
• The indicator may do a poor job of capturing what it's trying to measure.
  Indicators that are especially likely to be weak in this regard include those based only on number of procedures and those based on billing data (the AHRQ Patient Safety Indicators and Inpatient Quality Indicators use billing data).
• The indicator's risk adjustment statistical model may not take into account all the factors that it should, so the hospital is not getting full credit for the complexity of its cases.

8. How often will the data on this report be updated?

At least quarterly as new data become available.