Quality and Safety

Fast Facts

• Quality care ratings are a simple, efficient way to measure the level of care a hospital provides.
• Quality care ratings are also a way to better understand a hospital’s practice when it comes to patient safety.
• Reviewing quality care ratings helps patients choose the best care for their healthcare goals and needs.

What It Means

Every day, the providers and staff at Central Maine Healthcare strive to deliver the highest quality care. That means caring for patients without exposing them to additional harm, such as medical errors or hospital-acquired infections. We measure our success through quality of care ratings from independent agencies. These ratings allow us to measure how effectively we administer patient care, how affordable care is to our patients and how we compare to other healthcare facilities on a local and national scale.

How Are We Doing?

Central Maine Healthcare participates in quality care ratings from the Maine Health Data Organization (MHDO), the Maine Quality Forum (MQF) and The Leapfrog Group. The Leapfrog Group is a national nonprofit that scores hospitals twice a year and offers grades from A–F based on patient safety, quality care, and cost of care. More than half of the country’s hospitals voluntarily provide data to the Leapfrog Group.

When these third parties review our organization, they look at our rates of errors, injuries, accidents and hospital-acquired infections as well as our processes in place to address those issues. The staff at CMH facilities have made concerted efforts to improve quality,  CMMC receives a Hospital Safety Grade from Leapfrog and Bridgton and Rumford hospitals both participate by submitting the Leapfrog survey but they are only eligible for Top Rural Hospital.

Patients are welcome to review our data which is published on the Compare Maine web site sponsored by MHDO and MHQ:

• Central Maine Medical Center
• Bridgton Hospital
• Rumford Hospital

Constant Improvement

Under CEO Steve Littleson’s leadership, our facilities have used a combination of technology and strategic partnerships with other local healthcare providers to improve access to high-quality care while also lowering costs for patients. CMH has received national quality and safety accreditations in many fields, including advanced primary stroke, bariatric surgery and rehabilitation medicine.

Fast Facts

• Transparency about health care leads to higher patient satisfaction and increased trust. In turn, increased trust leads to increased compliance with discharge instructions and follow-up care — which leads to better patient outcomes.
• Holding team members accountable ensures continuous improvement, and a culture of accountability increases staff satisfaction.
• Patient experience improvement is a vital part of any organization that is serious about offering superior service.

What It Means

Patient satisfaction and patient experience are both important, but they are two different measurements at Central Maine Healthcare. Patient satisfaction focuses on whether a patient’s expectations about a health encounter were met. Patient experience seeks to understand from patients whether something that should happen in a healthcare setting actually happened — the range of interactions patients have across the continuum of the healthcare system, including care from providers, nurses, specialists and everyone else who works in our facilities.

At CMH, we select a random assortment of patients to complete Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys to help us gauge their experiences at CMH. The 32-item survey allows patients to rate everything from the temperature of their hospital room and the quality of their food to their communication with nurses and the amount of time providers spent with them.

How Are We Doing?

Data from our HCAHPS survey is submitted to the Centers for Medicare & Medicaid Services (CMS), the federal agency within the United States Department of Health and Human Services that administers the Medicare and Medicaid program. The survey data account for 25% of CMS’s formula for calculating value-based payment to hospitals. You can compare our results here:

• Central Maine Medical Center
• Bridgton Hospital
• Rumford Hospital

Fast Facts

• Healthcare facilities are places for patients to seek care to improve their health, not acquire an infection as a consequence of their hospital stay or procedure. Central Maine Healthcare follows the necessary protocols to provide a safe environment for staff, patients and visitors.
• Infection prevention is promoted through education about hand hygiene, the importance of vaccinations and proper use of antibiotics.
• Our infection prevention team provides support so staff can identify someone with an infectious disease and quickly institute precautions. Each CMH facility has dedicated rooms, disinfection supplies and personal protective equipment (PPE) that help prevent the spread of disease.

What It Means

Infection prevention is the practice of identifying any risks of contamination and following set processes to prevent potential harm to staff, patients and visitors. The World Health Organization reports 1 in 10 patients acquire a healthcare-related infection. CMH infection prevention teams are trained to minimize the spread of infectious disease and are accessible to every department to serve as consultants to healthcare personnel.

At CMH, we follow a set of standardized ratings to determine whether patients meet the criteria for an infection during their hospital stays. We also use a Centers for Disease Control and Prevention sponsored national database called the National Health Safety Network. The database calculates a number called a standardized infection ratio based on the type of hospital, risk of patient, number of patients cared for and other risk indicators. The publicly available number demonstrates how well our hospital compares with others locally and around the country.

We monitor all:

• Bloodstream infections related to central lines
• Clostridiodes difficile (C. diff) infections
• Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections
• Surgical site infections
• Urinary tract infections related to indwelling catheters
• Ventilator-associated events

How Are We Doing?

CMH reports infection prevention results to the Centers for Medicare & Medicaid Services for our three locations:

• Central Maine Medical Center
• Bridgton Hospital
• Rumford Hospital

Not only do hospital ratings provide patients the opportunity to compare hospitals, but they also hold us accountable for continual improvement.

CMH includes infection prevention in its core education for all staff from initial hire to annual trainings. Our staff receives annual supplemental education on topics such as hand hygiene, PPE compliance, isolation precautions, specific disease processes, equipment disinfection and resistant microorganisms.

Constant Improvement

CMH strives to provide the highest quality patient care. Patients can trust their safety is our top concern. We have made it our goals to:

• Reach 90% compliance in the area of hand hygiene
• Institute initiatives to prevent surgical site infections for colon surgery patients
• Keep staff updated about new and emerging information about COVID-19 and follow set policies to prevent spread of infection

Bringing Perspective to Infection Prevention

Joanne Kenny-Lynch, M.S., M(ASCP), CIC, system director of infection prevention, has been a practicing infection preventionist since 1992 and joined CMH in 2018. She helps oversee infection prevention at CMMC, Rumford Hospital, Bridgton Hospital, all CMH outpatient practice locations and Maine Urgent Care facilities. She also has a consultative role with Bolster Heights Residential Care and Rumford Community Home. She is proud to play a role in promoting infection prevention at CMH facilities.

“I’d like to say I have helped give my team a voice and shown how important infection prevention is,” Kenny-Lynch says. “Our team actively participates in all aspects of patient care, from room cleaning to providing guidance on new construction and renovations performed at the facilities. We play a part in every single department in our center, because in some way, everyone comes in contact with a patient. While we are not seen in the forefront as patient caregivers, the positive impact of our role in patient care at CMH is huge.”

Fast Facts

• Hospital readmissions are associated with unfavorable patient outcomes.
• The hospital readmissions metric encourages healthcare facilities to involve patients and families in discharge planning.
• Reducing hospital readmissions saves tax dollars.

What It Means

A variety of factors can lead patients to be readmitted to the hospital days or weeks after discharge, including drug-related complications, a hospital-acquired infection, complications resulting from surgery, lack of education about a care plan or an inadequate support network that makes compliance with providers’ instructions difficult.

Hospital readmissions are costly. The Centers for Medicare & Medicaid Services (CMS) issues penalties for hospital readmissions and offers incentives for hospitals to reduce them as part of its Hospital Readmissions Reduction Program (HRRP). CMS policies consider hospital readmission rates as a way to gauge quality of patient care. CMS defines a hospital readmission as an unplanned readmission that happens within 30 days of discharge from an initial admission. As part of the HRRP, CMS tracks hospital readmissions for heart attack, chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, coronary artery bypass graft surgery, and elective total hip and total knee replacements.

CMS measures hospital quality in three categories: structural measures, process measures and outcome measures. Hospital readmissions are part of the outcome measures category. CMS obtains readmissions data from coded claims submitted by hospitals for payment, which makes them available on the Medicare Hospital Compare website.

Hospital readmissions cost the United States billions of dollars annually, which increases taxes for everyone. Lowering readmissions can decrease healthcare costs and increase quality of care and patient satisfaction.

 How Are We Doing?

Central Maine Healthcare’s hospital readmissions data can be found on the CMS website. CMS obtains readmission data from coded claims submitted by hospitals for payment.  See how we’re doing by checking out the numbers for:

• Central Maine Medical Center
• Bridgton Hospital
• Rumford Hospital

Constant Improvement

At CMH, our goal is to reduce hospital readmissions to less than 10%. A recent data analysis found that congestive heart failure, COPD and diabetes are our top readmission diagnoses. That led us to prioritize several steps to decrease readmissions, including increasing targeted patient education, setting up clinical pathways to produce more successful hospital stays and increasing family involvement in discharge planning and education. We’re developing clinical pathways focused on diagnosis, patient education, nutrition and the importance of follow-up treatment. We’re also exploring the possibility of developing clinics to encourage follow-up visits within 72 hours of discharge.

Bringing Perspective to Hospital Readmissions: Care Management

Some hospital readmissions are avoidable, and others aren’t. To increase patient satisfaction, CMH and our communities must work as a team to ensure patients leave the hospital understanding their instructions for continuing care at home. Educating the community about the importance of avoiding readmissions is important to decrease healthcare costs for all.

We have an amazing team of case managers that includes nurses and social workers. We support this team in safely discharging patients to the next level of care by identifying challenges to success early in the hospital stay and finding solutions. The team helps patients avoid readmission by ensuring they have the support they need upon discharge. This could be home health services, admission to a skilled nursing facility or outside support systems.

Our philosophy is to treat others as we would want to be treated. Meeting patients at their level helps us understand their needs and support a safe discharge plan. Our job is rewarding because we break down barriers for patients.

Fast Facts

• Core measures promote evidence-based patient care.
• Core measures help ensure patients receive care that will lead to better outcomes.
• Core measure compliance results enable patients and their families to make informed decisions about where they receive care.

What It Means

Core measures are national standards of care for common conditions. These standards are based on research, reduce patient complications and improve outcomes. Learning a hospital’s core measure compliance helps patients understand how their hospital compares to its competitors. Core measure compliance shows how often a hospital provides the recommended treatment for these common conditions — hospitals with higher compliance often produce better patient outcomes.

Core measures focus on four sets of criteria:

• Research — providing patient care supported by strong scientific evidence
• Proximity — offering care with few “pit stops” between diagnosis and improved patient outcomes
• Accuracy — measuring the effectiveness and efficiency of care to help make positive outcomes more likely
• Adverse effects — reducing or eliminating the potential for negative side effects during care delivery

How Are We Doing?

Each of our hospitals reports our core measure compliance to The Joint Commission and the Centers for Medicare & Medicaid Services, and we make our results available to the public:

• Central Maine Medical Center
• Bridgton Hospital
• Rumford Hospital

Constant Improvement

Central Maine Healthcare has worked to improve core measure performance in several areas with remarkable results. Most recently, CMMC, Bridgton Hospital and Rumford Hospital have created multidisciplinary stroke and sepsis teams that include providers, nurses, pharmacists and more. The sepsis team has followed the recommendations of the Surviving Sepsis Campaign, a global initiative to reduce mortality related to sepsis — a life-threatening reaction to infection. Compliance percentages for the core measures for sepsis care have steadily increased since 2015. CMMC ranks at 77%, Bridgton Hospital at 87%, and Rumford Hospital at 66%. For comparison, the average score in the state of Maine is 62%, and the national average is only 59%.

Q&A With System Director of Rehabilitative and Orthopedic Services, Elizabeth Turcotte, MSN, RN-BC, ONC

Improving core measures in the treatment of stroke has been one area that CMH has made a priority. Our multidisciplinary stroke team regularly reviews scientific literature to identify and implement best practices in treating stroke quickly while also reviewing every case to determine if processes need to change.

“As stroke coordinator, I ensure that our team implements and follows the most up-to-date standards of stroke care,” says. Elizabeth Turcotte, MSN, RN-BC, ONC “Core measures ensure we provide the highest quality of care to promote positive outcomes. They provide a cohesive framework based on national recommendations, providing clear guidance and unifying patient care.”

Core measures also ensure consistency with medication, imaging, treatment and follow up, Turcotte adds.

“My goal is to ensure our Stroke Program functions at an optimal level,” she says.  “I work with staff, outlying providers, patients and the community to provide education, quality improvement and resources for this potentially debilitating condition.”

In compliance with Section 1557 and other federal civil rights laws, we provide individuals the following in a timely manner and free of charge:
• Language assistance services. CMH will provide language assistance services for individuals with limited English proficiency (including individuals’ companions with limited English proficiency) to ensure meaningful access to our programs, activities, services, and other benefits. Language assistance services may include:
o Electronic and/or written translated documents
o Qualified interpreters
• Appropriate auxiliary aids and services. CMH will provide appropriate auxiliary aids and services for individuals with disabilities (including individuals’ companions with disabilities) to ensure effective communication. Appropriate auxiliary aids and services may include:
o Qualified interpreters, including American Sign Language interpreters
o Video remote interpreting
o Information in alternate formats (including but not limited to large print, recorded audio, and accessible electronic formats)
o Qualified readers
• Reasonable modifications. CMH will provide reasonable modifications for qualified individuals with disabilities, (including individuals’ companions with limited English proficiency) when necessary to ensure accessibility and equal opportunity to participate in our programs, activities, services, or other benefits.

To access services for language assistance, auxiliary aids, and/or to obtain reasonable modifications, please ask a CMH team member for assistance.

For additional assistance, you may contact the Section 1557 Coordinator at 207-795-2906 or by mail to 300 Main St., Lewiston, ME 04240.

If you believe CMH has failed to provide these services or has discriminated in another way based on race, color, national origin, sex, age, or disability call the Patient Relations/Compliance Hotline at 207-795-2895 or 207-795-2906.

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:
• Electronically: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
• Via mail: U.S. Department of Health & Human Services 200 Independence Avenue, S.W. – 509F Washington, D.C. 20201