Quality Transparency

As part of the Antelope Valley Medical Center mission, we strive to be a provider of choice for all essential healthcare services, however, it’s just as important to AVMC in making sure we are also providing the best quality health care. As the largest hospital of the Antelope Valley, quality care, patient safety and satisfaction are vital to AVMC.

The Hospital Quality Institute (HQI)’s quality transparency dashboard is a tool used to help patients see how individual hospitals perform important quality measures, in comparison against national and state levels (note, lower numbers are indicative of better performance). Antelope Valley Medical Center is working closely with HQI to increase transparency and provide our patient community with safety data to help empower them in making the best choices when it comes to their health care.

Antelope Valley Medical Center is committed to improving patient safety and quality of care.

Program Status Measures:

• This hospital has a Maternity Safety Program in place. A maternity safety program provides a coordinated approach and emergency response to risks associated with pregnancy and childbirth.
• This hospital has a Sepsis Protocol in place. A sepsis protocol provides guidance for a coordinated approach to identification and treatment of an infection and inflammatory response which is present throughout the body.
• This hospital has a Respiratory Monitoring program in place. Respiratory monitoring provides guidance for assessment of risk of respiratory depression, and includes continuous monitoring of breathing and functioning of the lungs and circulatory system when indicated.

CLABSI - Central line-Associated Blood Stream Infection: A serious infection that occurs when germs enter the bloodstream through a central line. A central line is a special intravenous catheter (IV) that allows access to a major vein close to the heart and can stay in place for weeks or months. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitations: In the calculation of the Standardized Infection Ratio (SIR), the CDC adjusts for differences between hospitals. However, patient risk factors are not taken into account. These patient-specific variables (e.g., poor skin integrity, immunosuppression) can increase the risk of developing a central line infection. Hence, the SIR for hospitals that care for more medically complex or immunosuppressed patients may not be adequately adjusted to account for those patient-specific risk factors.

Antelope Valley Medical Center	California Level	National Level
0.62	0.67	0.69

Colon SSI - Colon Surgical Site Infection: An infection (usually bacteria) that occurs after a person has colorectal surgery that occurs at the body site where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, organs, or implanted material. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitations: Some, but not all patient-specific risk factors are included in the adjustment of the SIR for these types of infections. However, not all relevant risk factors are included (e.g., trauma, emergency procedures). Hence, the SIRs for hospitals performing more complex procedures or with larger volumes of trauma or emergency procedures may not be adequately adjusted to account for those patient-specific risk factors.

Antelope Valley Medical Center	California Level	National Level
0.60	0.86	0.87

NTSV - Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate: The percentage of cesarean (surgical) births among first-time mothers who are at least 37 weeks pregnant with one baby in a head down position (not breech or transverse). Lower values indicate that fewer cesareans were performed in the hospital among primarily low risk, first-time mothers. Limitations: NTSV rates do not take into account certain obstetric conditions, such as placenta previa, that may make Cesarean delivery the safer route for both mother and infant.

Antelope Valley Medical Center	California Level	National Level
24.70	22.90	25.60

Sepsis Mortality: Percent of patients, with a severe infection, who die in the hospital. Most sepsis cases (over 90%) start outside the hospital. Lower percentage of death indicates better survival. Limitations: Use of discharge/administrative data is limiting since such data has lower specificity for diagnoses than clinical data. In addition, without risk adjustment for differences in patient-specific factors, comparing rates among hospitals is difficult.

Antelope Valley Medical Center	California Level	National Level
22.46	14.30	25.00

30-day Readmission - Hospital-wide All-Cause 30-day Unplanned Readmission Rate: The percentage of patients who were unexpectedly readmitted within 30 days of discharge from the hospital for any reason. Lower values indicate that fewer cases were unexpectedly readmitted after discharge. Limitations: Some, but not all patient-specific risk factors are included in the adjustment of the readmission rate. However, not all relevant risk factors are included (e.g., trauma, emergency procedures).

Antelope Valley Medical Center	California Level	National Level
15.90	15.48	15.60

Community Health Needs Assessment

AVMC uses the Los Angeles County Department of Public Health, Key Indicators of Health report to help illustrate the health needs of the Antelope Valley, in order to develop priorities that will care for the evolving needs of the communities in which we serve.

Key Indicators are standardized measures through which health and well-being are assessed. The report describes indicators for each of Los Angeles County's eight Service Planning Areas (SPAs) and the County overall---Antelope Valley is considered SPA 1.