Quality and Patient Safety


At Cayuga Medical Center, our caregivers are committed to providing patient care that is both safe and of the highest quality. We continuously refine the care we provide, we monitor and measure the treatments our patients receive, and we evaluate our performance against our own strict criteria and national health-care benchmarks.


At Cayuga Medical Center, we define quality as:


  exceptional care and outcomes

  extraordinary patient safety

  superior service and patient satisfaction


Our progress in achieving and maintaining the highest standards of care is recognized within the health care industry by our accreditations and activities. Cayuga Medical Center is:


  Accredited by the Joint Commission on Accreditation of Healthcare Organizations and is a Hospital Quality Alliance Participant. Accreditation by the Joint Commission means that Cayuga Medical Center has demonstrated compliance with national standards for patient safety and quality of care.


  An affiliate of the Rochester Heart Institute, working to provide the foremost cardiac care possible.


  An affiliate with Mayo Laboratory Clinic, one of the nation’s leaders in patient care.


  A premier affiliate of Roswell Park Cancer Institute, a comprehensive cancer institute, one of only 41 in the United States.


  A Certified Stoke Center, designated by the New York State Department of Health. This means that Cayuga Medical Center is fully equipped to meet the latest standards for the prompt diagnosis and treatment of patients with a diagnosis of stroke.


  A New York State Department of Health designated Level 2 Perinatal Center. This means that our Maternal-Child Health Unit is fully equipped and prepared to meet the special needs of women and newborns who are at moderate risk, and that the medical center operates a neonatal intensive care unit (NICU).


In this day and age, you can choose between many health care facilities. It’s important that you have the knowledge to make informed decisions about where to seek care for your condition. Because these health care decisions can be complex, we plan to update and add to this information regularly. In this way, we can help you evaluate the various state and federal studies that rate hospital performances and help you understand what Cayuga Medical Center is doing to monitor and improve our own performance.


To read more about quality and patient safety at Cayuga Medical Center and to learn what kind of methods we employ for performance improvement, just click on the links below.


       Maintaining quality performance

       Pursuing perfection

       Utilizing Quality Measures

       Recent Quality Initiatives

       Publicly Reported Data


Maintaining quality performance


The science of quality improvement is advancing and the ability to apply this science is crucial to the future of health care. Through academic opportunities and continuing education for our professional staff, Cayuga Medical Center staff has established successful programs to:


  measure quality of care

  assess and benchmark practices to help us improve

  design and test interventions

  identify errors in care

  implement safety design principles

  create interdisciplinary teams to help implement change strategies


Ongoing quality performance improvement and management is maintained continuously within and among the medical center departments. Monthly reports and associated data are forwarded to the quality management department and the summaries are examined by the leadership teams and departments. The aggregated data is reviewed at our monthly staff meetings. This provides our staff with an open learning environment that supports service excellence and the delivery of quality patient care.


Pursuing Perfection


Our goal in pursuing impeccable care at Cayuga Medical Center is to refine the quality of health care we provide to our patients. We work hard to provide you with efficient, effective, patient-centered, equitable, safe care. And by placing you at the center of our health-care team, we empower you and your loved ones to take an active role in your care and healing process. We strive every day to implement evidence-based approaches designed to improve the quality and efficiency of your care.



Utilizing Quality Measures


Organizations like ours use specific quality measures to evaluate how well we provide care to our patients. These measures are based on scientific evidence and reflect guidelines, standards of care, and practice parameters. A quality measure transforms medical information from patient records into a rate or percentage that allows organizations to gauge their performance.


At Cayuga Medical Center, we closely monitor the quality of the care and services we provide by measuring what we do and how we do it. We also listen carefully to what our patients and community have to say about us. The information and feedback we gather is used to develop positive changes in the way we provide care.


Quality measures can help you evaluate the performance of various health care institutions. This information can be used in assessing and selecting the optimal health care option for you and your family.


Quality measures tell you:


  whether or not health care institutions are providing care in a timely way

  whether or not the care is effective and safe

  whether or not the care is patient-focused

  the experience and success rate of treatment of particular diseases and conditions


Recent Quality Initiatives


Cayuga Medical Center is intently focused on improving our health care delivery. Our goal is to address all aspects of quality, resulting in superior patient care. Some of our most recent improvements have focused on three key changes in health care:


  Ventilator Acquired Pneumonia (VAP)

  Codes Outside the Intensive Care Unit

  Central Venous Catheter (CVC) -Related Infections



Ventilator Acquired Pneumonia (VAP)


Ventilator-associated pneumonia (VAP) is a pneumonia that affects hospitalized patients who are on ventilators. VAP makes oxygen exchange difficult and is a particular risk for patients who are on mechanical ventilation for more than 48 hours.


Nationwide, ventilator-associated pneumonia (VAP) continues to complicate the course of 8% to 28% of patients receiving mechanical ventilation. The mortality rate for VAP ranges from 24% to 50% and can reach 76% in certain settings or when the pneumonia is triggered by high-risk bacteria or virus. Moreover, it is estimated that VAP adds an additional estimated cost of $40,000 to a typical admission.


At Cayuga Medical Center, we use a special ventilator protocol to reduce the risk of VAP. The ventilator protocol is a series of specific steps related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually. The key components of the ventilator protocol are:


  Elevating the head of the bed to greater than 30 degrees

  Daily deep vein thrombosis (DVT) prevention

  Daily stress ulcer disease (SUD) prevention

  Daily assessment of readiness to wean off the ventilator

  Daily sedation reduction

  Daily spontaneous breathing trial


The Institute for Healthcare Improvement (IHI) recommends that all elements of a ventilator protocol be fully implemented to improve the clinical outcomes of mechanically ventilated patients. Cayuga Medical Center’s success with controlling VAP has been recognized by the New York State Department of Health Patient Safety Award for Large Hospitals.



Rapid Response Team


Cayuga Medical Center recently formed a rapid response Clinical Assessment Team (CAT) to help prevent cardiopulmonary arrests in inpatients outside of the Intensive/Cardiac Care Unit. The team is available 24 hours a day and can be called at any time by a health care provider, family member, or visitor.


This team of critical care specialists is available to respond to patients throughout the medical center who have a noticeable, unexplained, or unexpected change in condition. The purpose of our team is to immediately bring a critical care level of expertise to the patient’s bedside. Together, the team members assess the patient’s condition, initiate treatments that may stabilize or correct the patient’s condition, and transfer the patient to a higher level of care if indicated.


Since the initiation of our CAT program in January 2006, we have seen a dramatic decrease in the incidence of patients experiencing cardiac or respiratory arrest on the inpatient units outside of the Intensive/Cardiac Care Unit. This program is part of the One Million Lives Campaign initiated by the Institute for Health Care Improvement, the goal of which has been to help our nation’s hospitals improve patient care and prevent avoidable deaths.



Central Venous Catheter (CVC) -Related Infections


Central Venous Catheters (CVCs) are used to administer medications, intravenous fluids, and nutritional supplements. However, the insertion of a CVC creates a tiny opening in the skin, which raises the risk of infection. When these infections occur, they may spread to the bloodstream, which can lead to changes in blood pressure and fluid balance, organ dysfunction, and, in extreme cases, death. In fact, bacterial infections of the blood arising from central venous catheters are among the most common hospital-acquired infections in the intensive care unit.


Cayuga Medical Center utilizes a central line protocol to prevent central venous catheter-related infections. The central line protocol is a series of steps related to the care of patients with central venous catheters that, when implemented together, result in better outcomes than when implemented individually. The central line protocol includes:


  hand hygiene

  maximal barrier precautions

  chlorhexidine skin prep

  optimal site selection

  daily review of line necessity


Furthermore, patients and their loved ones are encouraged to monitor hand hygiene practices and remind physicians and nurses to wash their hands.



Publicly Reported Data



The Joint Commission has had a longstanding commitment to providing meaningful information about the comparative performance of accredited organizations to the public. In 1994, The Joint Commission first published organization-specific Performance Reports. In 1996, Quality Check, a directory of Joint Commission accredited organizations and performance reports, became available on the website.

View Online Quality Report

New York State Department of Health

The New York State Department of Health is dedicated to ensuring quality health care in all of the State’s health care facilities. They strive toward this goal by measuring the care rendered to patients in comparison to a code of rules and regulations which all facilities must follow. This code involves minimum standards of care which facilities are required to provide.

View Online Hospital Profile

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