2018 Quality Transparency Dashboard

Patient safety, satisfaction, and quality of care are key to Cedars-Sinai Marina del Rey Hospital’s mission. That is why we’re committed to working closely with the Hospital Quality Institute (HQI), the Patient Safety Movement Foundation (PSMF) and the California Hospital Association (CHA) to increase transparency in our patient-safety data and empower you to make the best decisions about your healthcare.

This Quality Transparency Dashboard displays the outcome measures and program status for Cedars-Sinai Marina del Rey Hospital. It provides transparency to how this hospital is performing among five key quality-of-care metrics, compared to hospitals across California and the nation.

Patients can be confident in our commitment to improving safety and quality of care on a continual basis. Our goal is to make Cedars-Sinai Marina del Rey Hospital one of the safest hospitals in the nation.

Central Line-Associated Bloodstream Infection (CLABSI)

Measure Period: 07/01/2018–06/30/2019

Cedars-Sinai Marina del Rey Hospital	California Level	National Level
0.000	0.79	0.77

Central line-associated bloodstream infection (CLABSI): This is a serious infection that occurs when germs enter the bloodstream through a central line (a special intravenous catheter that allows access to a major vein close to the heart, and which 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 a certain period of time. SIRs below 1.00 indicate that the observed number of infections during the measured period was lower than would be expected under normal conditions, while values above 1.00 indicate that the observed number of infections was higher than expected.

Limitation: When calculating the SIR, the Centers for Disease Control and Prevention (CDC) adjust for differences between hospitals, but patient risk factors aren’t considered. These patient-specific variables (such as poor skin integrity or a suppressed immune system) can increase the risk of developing a central line infection. As a result, 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.

Colorectal Surgical-Site Infection (SSI)

Measure Period: 10/01/2017–09/30/2018

Cedars-Sinai Marina del Rey Hospital	California Level	National Level
0.00	0.98	0.90

Colorectal surgical-site infection (SSI): An infection (usually bacterial) that occurs after a person has had colorectal surgery, which occurs at the site on the body where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, the organs, or implanted material. The value shown above is a standardized infection ratio (SIR), which is the ratio of observed-to-expected infections during a certain period of time. SIRs below 1.00 indicate that the observed number of infections during the measured period was lower than would be expected under normal conditions, while values above 1.00 indicate that the observed number of infections was higher than expected.

Limitation: Some patient-specific risk factors are included in the adjustment of the SIR for these types of infections, but not all (such as trauma or emergency procedures). As a result, the SIR for hospitals that perform 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.

Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate

Measure Period: 01/01/2018 - 12/31/2018

Cedars-Sinai Marina del Rey Hospital	California Level	National Level
Not Applicable	23.50%	25.90%

Nulliparous, Term, Singleton, Vertex (NTSV) cesarean birth rate: This is the percentage of cesarean (surgical) births that occur among primarily low-risk, 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 among this group of mothers.

Limitation: NTSV rates don’t take into account certain obstetric conditions, such as placenta previa, that may make a cesarean delivery the safer route for both mother and infant.

Sepsis Mortality

Measure Period: 01/01/2018 - 12/31/2018

Cedars-Sinai Marina del Rey Hospital	California Level	National Level
11.31%	14.30%	25.0%

Sepsis mortality: This is the percentage of patients with a severe infection who die in the hospital. Most cases of sepsis (over 90%) start outside the hospital. A lower percentage indicates better survival rates.

Limitation: The use of discharge/administrative data is less specific than clinical data in providing a diagnosis. In addition, without adjusting for differences in patient-specific risk factors, comparing rates among hospitals is difficult.

Venous Thromboembolism

Measure Period: 10/01/2017–09/30/2018

Cedars-Sinai Marina del Rey Hospital	California Level	National Level
0.00	3.0%	3.0%

Venous thromboembolism (VTE): The measure of patients who developed deep-vein blood clots and who hadn’t received potentially preventive treatment.

Limitation: Although this rate isn’t adjusted to account for patient-specific risk factors, it’s helpful in distinguishing a hospital’s adherence to the best practice of administering appropriate VTE prophylaxis (preventive measures) to all appropriate patients.

Program Status Measures

Maternity Safety Program

This hospital does not have a maternity program.

Sepsis Protocol

This hospital has a sepsis protocol in place. The protocol provides guidance for a coordinated approach to the identification and treatment of a serious infection that can result in damage to multiple organ systems, causing them to fail.

Respiratory Monitoring Program

This hospital has a respiratory monitoring program in place. The program provides guidance for the assessment of the risk of respiratory depression and includes continuous monitoring of breathing, and functioning of the lungs and circulatory system when indicated.