a Report Community to the
Dear Community Member, For many years, finding a way to measure the quality of healthcare programs and services was an inexact science, dependent mostly on opinion and hearsay. Today, with the availability of information from an ever-growing number of sources television, newspapers, radio, books, and the internet we have a roadmap. Through research, a consumer can find objective measures that include clinical outcomes or success rates for specific procedures, surveys by accrediting bodies, and published national standards for many areas, including patient satisfaction. Consumers can also learn how hospitals, as not-for-profit organizations, meet their community benefit obligations by giving back to the communities they serve. This Report to the Community offers a look into some of the many ways that quality is measured at The Valley Hospital and how Valley gives back to the communities it serves. Sincerely, Audrey Meyers, President and Chief Executive Officer The Valley Hospital
Quality and Patient Safety Our Commitment to Quality and Patient Safety To bring the latest in patient safety to Valley, the Hospital participates in the Patient Safety Leadership Fellowship program. The program is a national, year-long intensive learning experience designed to teach leaders the latest advances in patient safety. Valley has 10 Fellows who have implemented many innovative strategies to enhance patient safety at Valley. The Valley Hospital has more Patient Safety Leadership Fellows professionals who have a national designation noting advanced learning in patient safety than any other hospital in the country. Source: Health Research & Educational Trust The Joint Commission An independent, not-for-profit organization, The Joint Commission accredits and certifies healthcare organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization s commitment to meeting specific performance standards. The Valley Hospital is proud to have received this accreditation for the entire hospital, with additional certifications awarded to the following programs and services: Valley Uses Technology to Improve Quality Valley is in the process of implementing a number of computerized systems designed to help clinicians provide excellent care to patients while minimizing the chance of making an error. The systems include computerized physician order entry (CPOE), bedside medication administration (BMV), and a specimen collection system. Quality Initiatives Save Lives Over the past five years Valley has participated in many quality initiatives to support the Institute for Healthcare Improvement s effort to save 100,000 Lives and more recently, 5 Million Lives. Efforts at Valley have been successful in reducing medication errors, incidences of ventilator associated pneumonia, falls, and mortality. During the time that Valley has participated in these efforts, more than 450 lives have been saved. Source: Internal Data - The Valley Hospital Valley has been recognized with the New Jersey Governor s Quality Award for Performance Excellence. Quality and Patient Safety Acute Myocardial Infarction (Heart Attack) Heart Failure Advanced Primary Stroke Center Hip Replacement Knee Replacement Prostate Cancer Colon/Rectal Cancer Breast Cancer Pancreatic Cancer Lung Cancer Board Certification Board certification means that a doctor has undergone the extra years of training and passed the necessary examination to be accredited by a recognized medical or surgical specialty organization. Many practitioners are certified in subspecialties as well, such as cardiology, cardiothoracic surgery, and neonatology. Board certification indicates a high level of competence as measured by the doctor s specialty. Valley is one of only four hospitals in the nation to have 10 or more certifications from The Joint Commission. Board-Certified Physicians 94% Source: The Joint Commission National Average 85% Source: American Board of Medical Specialties
N u r s i n g Nursing MAGNET AWARD FOR NURSING EXCELLENCE Valley Nurses have been twice honored with the Magnet Award for Nursing Excellence from the American Nurses Credentialing Center. The Magnet Award is the nursing profession s highest form of recognition. Press Ganey Overall Nursing Percentile Rank 98% 98% 96% N u r s i n g VALLEY NURSES EARN HIGHEST SCORES Research indicates that many people equate their feelings about their hospital stay with the care they receive from the hospital s nurses. In a recent federal study of patient satisfaction that included a question regarding nurses communication with their patients, Valley nurses scored highest among all hospitals in the region and higher than the national and state average. Percent of patients who reported that their nurses Always communicated well 80% 90% 2004 2005 2006 The scores shown above reflect how Valley patients scored Valley nurses overall with respect to the following areas: Friendliness/courtesy of the nurses Promptness in responding to the call button Nurses' attitude toward your requests Amount of attention paid to your special or personal needs How well the nurses kept you informed Skill of the nurses Bergen County Average 72% Source: Press Ganey New Jersey Average 71% VALLEY NURSES ARE HIGHLY EDUCATED AND WELL-TRAINED United States Average 74% Percent of Nurses holding Bachelor s of Science in Nursing Source: The Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS. For information please visit www.hospitalcompare.hhs.gov. National Average 46% 53% Valley s Intensive Care, Cardiac Surgery Intensive Care, Coronary Care, and Intermediate Care Units have all received the Beacon Award for Critical Care Excellence from the American Association of Critical-Care Nurses. Source: National Database for Nursing Quality Indicators ADVANCED PRACTICE NURSES Valley has Advanced Practice Nurses (APNs) who are Registered Nurses with advanced education, knowledge, skills, and scope of practice. They work with other nurses on a day-to-day basis, participating in daily clinical rounds. They maintain national certification in their specialty, such as critical care, palliative care, adult, and family nursing.
P a t i e n t A c t i v i t y Patient Activity The Valley Hospital is the second busiest hospital in New Jersey based on admissions. In, more patients were admitted to The Valley Hospital than ever before. HOSPITAL USAGE Total Admissions...47,177...48,282 Emergency Room Visits...54,159...66,553 All Surgeries...15,916...17,971 Valley has been recognized by HealthGrades, the healthcare quality ratings company, as being in the top 10 percent in the nation for overall cardiac services which includes cardiac surgery and the top 10 percent in the nation for cardiology services. P a t i e n t A c t i v i t y CARDIOLOGY Cardiology stats* Valley has received the 2009 HealthGrades Cardiac Care Excellence Award and the 2009 HealthGrades Coronary Intervention Excellence Award. 34,116 38,680 *Cardiology patients include those treated for a variety of cardiac illnesses. Valley has been named the #1 program in New Jersey for coronary interventional procedures. Source: HealthGrades, Inc. Valley 's Cardiac Surgery program has been recognized three times with a three-star rating the highest possible recognition by The Society for Thoracic Surgeons for quality and clinical excellence. Only 12 percent of cardiac surgery programs nationwide qualify for this recognition. Valley s Coronary Interventional program is in the top 5 percent in the nation. CANCER CARE Valley was the first cancer program in New Jersey and the New York metropolitan area to be awarded Disease-Specific Care Certification from The Joint Commission. The report noted: The Cancer Program at Valley is a holistic, comprehensive, multidisciplinary program that addresses the needs of adults with a cancer diagnosis throughout the entire continuum of care. This hospital is able to rival larger medical centers and university programs in their use of evidence-based practice and participation in clinical trials and other research. Source: Report from The Joint Commission Newly Diagnosed Cancer Patients 1,533 Source: HealthGrades, Inc. 1,717
P a t i e n t A c t i v i t y ORTHOPEDICS Valley s Total Joint Replacement Center has been recognized by The Joint Commission for its excellence and quality. The Center was among the first in the nation to use Navigation Technology to improve surgery and is the only hospital in the region to be using an innovative procedure that greatly reduces the pain associated with knee replacement surgery. Total Joint Replacement Surgeries 462 665 OBSTETRICS Valley offers a full range of services for mothers and babies, including Maternal-Fetal Medicine, Obstetrics, Neonatology and In Vitro Fertilization and Reproductive Endocrinology. The Valley Hospital is a New Jersey Department of Health designated Neonatal Intensive Care Unit. At Valley's Center for Fertility, the percent of egg retrievals for women 40 and under that resulted in a live birth was 45 percent, 20 percentage points higher than the national average. P a t i e n t A c t i v i t y VALLEY HOME CARE The Valley Hospital is the #1 hospital in New Jersey for spine surgery. Source: HealthGrades, Inc. Valley Home Care offers a full spectrum of services delivered in patients homes to meet a variety of healthcare needs, from post-stroke physical therapy to post-surgical care and in-home cancer care. Source: Society for Assisted Reproductive Technology - www.sart.org In 2006, the year for which the most recent comparative data is available, Valley had the fourth busiest nursery in the state, welcoming more babies than 92 percent of hospitals with obstetric programs in New Jersey. Source: Thomson Reuters: The Market Planner Plus Valley Home Care was the first in the area to use Telemedicine, an online service that allows doctors and nurses to monitor a patient s condition while the patient remains in their home. Newborns 3,173 3,286 Referrals to Valley Home Care 10, 310 11, 823 Source: The Valley Home Care Comparative Statistics Report
P a t i e n t S a t i s f a c t i o n Patient Satisfaction At Valley we continue to believe that the most important measure of what we do is patient satisfaction. It is what our patients think of us that matters most. Valley uses the largest patient satisfaction organization in the nation, Press Ganey, to measure its patient satisfaction. Over the past several years, Valley has worked hard to improve its patient satisfaction. The results, which placed Valley in the 95th percentile nationally, are proof of our success. Inpatient Satisfaction 87% 87% 92% 97% 95% Same Day Surgery Patient Satisfaction 96% 96% 2003 2004 2005 2006 For the fifth consecutive time, Valley has received the J.D. Power and Associates Distinguished Hospital Award for Service Excellence for providing an outstanding patient experience. P a t i e n t S a t i s f a c t i o n 74% 2003 2004 2005 2006 Emergency Department Patient Satisfaction According to a recent national patient satisfaction survey,* Valley was the highest ranked general acute care hospital in New Jersey in the following areas: Willingness to Recommend the Hospital and Having an Overall Rating of 9 or 10. Percent of patients who reported YES, they would definitely recommend the hospital 88% 94% 92% 83% 80% 78% 75% Bergen County Average New Jersey Average 62% 75% 2003 2004 2005 2006 United States Average 68% Outpatient Patient Satisfaction Percent of patients who gave their hospital a rating of 9 or 10 on a 0 (lowest) to 10 (highest) scale 89% 89% 90% 96% 93% Bergen County Average 67% 75% New Jersey Average United States Average 57% 64% 2003 2004 2005 2006 Source: Press Ganey Source: The Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS.* For information please visit www.hospitalcompare.hhs.gov.
Community Benefits Efficiency One common measure of hospital efficiency is the total cost for each admission. Of course, this number must be adjusted for the type of admission. A patient having a normal labor and delivery does not stay as long or use as many resources as the patient undergoing heart surgery. When all patient stays are adjusted for severity of illness, comparisons can be made. Here we compare ourselves to the data for New Jersey hospitals as a whole. Total Expenses per Admission* Valley - $5,565 (Second lowest in New Jersey) New Jersey Acute Care Hospital Total Expenses per Adjusted Admission Average - $8,482 * Case Mix Index Adjusted per the New Jersey Financial Analysis and Statistical Trends Report Valley is a not-forprofit organization. Money is invested back into programs, services, and technology to meet the healthcare needs of the community. In Valley provided: more than $40 million in uncompensated care attributable to charity care, bad debt, and Medicare and Medicaid shortfalls. primary and specialized care to patients during 8,182 visits recorded at Valley s Community Care clinic. health education, screenings, and support groups to more than 28,000 people. 28,700 at cost meals to homebound community members. Source: Internal Data - The Valley Hospital Valley also serves area youth by providing programs to meet their needs. Valley's Ridgewood Academy for Health Professions (RAHP), a partnership between The Valley Hospital and Ridgewood Public Schools, was recently recognized as a Model Academy by The National Career Academy Coalition (NCAC). The Coalition is comprised of professionals from education and other fields who review and evaluate Academy programs across the country. Valley's program is one of only three academies to have achieved Model status (the highest distinction) from the NCAC this year. In 2008, more than 100 students from Ridgewood High School attended the Academy. Economic Impact on New Jersey and Bergen County Community Benefits and The New Jersey Financial Analysis and Statistical Trends Report Valley is proud of the role it plays in Bergen County and the state. As the second largest employer in the County, Valley employs 4,206 full-time and part-time employees and impacts an additional 4,903 jobs in Bergen and Passaic Counties. Community Benefit In addition, Valley tenders approximately $12.8 million in payroll associated revenue to the State of New Jersey. Valley is a not-for-profit organization. What does this mean? It means that every dollar Valley makes goes back into serving our community. The funds are reinvested in new and needed technology, facilities, and healthcare programs and services, attracting and retaining the best doctors and staff, and improving the health of all those we serve. Source: Report from the Bergen County Department of Planning and Economic Development Community Benefit is a concept that generally applies to hospitals and the traditional role they play in the communities they serve. Historically, hospitals were granted tax exemption in return for the vital programs and services they provided the community. As the second largest employer in the County, Valley employs 4,206 full-time and part-time employees.
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