Quality & Safety Data
At RML Specialty Hospital, quality and safety are a top priority. We measure and review our monthly performance. This information is made available to patients, families, and clinicians, so they understand how care is evaluated and how we hold ourselves accountable.
The data reflects hospital-wide quality and safety measures reported through local and national organizations, including Medicare and Medicaid. These measures support transparency, learning, and continuous improvement across the hospital.
Commitment to Quality and Safety
Quality and safety data helps care teams review patterns, identify opportunities for improvement, and strengthen care processes across the hospital. These measures are one part of a broader approach that includes clinical expertise, multidisciplinary collaboration, and ongoing evaluation.
The data below reflects measures reported for groups of patients over time. These measures help identify patterns of care and do not predict individual outcomes.
CMS Reporting Key
Measure
- New or worsened pressure ulcers (lower is better)
- Catheter-associated urinary tract infections (CAUTI) (lower is better)
- Central line–associated bloodstream infections (CLABSI) (lower is better)
- Clostridium difficile (C. diff) infections (lower is better)
- Change in ability to move for patients admitted on a ventilator (higher is better)
- Patients assessed for readiness to begin ventilator breathing trials within first 2 days (higher is better)
- Patients on ventilators who appropriately received breathing trials within first 2 days (higher is better)
- Patients successfully weaned from the ventilator during LTCH stay (higher is better)
- Medication review with follow-up when issues were identified (higher is better)
- Potentially preventable hospital readmissions within 30 days (lower is better)`
- Discharge to home or community (higher is better)
Better Than National Benchmark
No Different Than the National Benchmark
Understanding the Measures
The measures below are used nationally to monitor quality and safety in long-term acute care hospitals. Each reflects care patterns across groups of patients and helps support review and improvement over time.
New or Worsened Pressure Ulcers
Pressure ulcers can develop when patients have limited mobility or spend extended periods of time in one position. They may be painful and can lead to complications if not carefully prevented and managed.
This measure helps care teams review how often pressure ulcers occur during a hospital stay and assess the effectiveness of prevention strategies such as repositioning, skin care, nutrition support, and the use of specialized surfaces.
Catheter-Associated Urinary Tract Infections (CAUTI)
Some patients require urinary catheters as part of their medical care. When catheters are used for extended periods or not managed carefully, infections can occur.
Tracking CAUTI rates helps hospitals evaluate catheter use practices and infection prevention efforts, particularly for patients receiving complex or prolonged care.
Central Line-Associated Bloodstream Infections (CLABSI)
Central lines are used to deliver important medications and treatments directly into the bloodstream. Because they provide direct access, careful handling is essential.
This measure supports review of bloodstream infection rates and helps teams assess line management, hygiene practices, and infection control protocols.
Clostridium difficile (C. diff) Infection
C. diff is a bacterium that can cause significant gastrointestinal illness, especially in patients who have received antibiotics or extended medical treatment.
Monitoring this measure helps hospitals evaluate antibiotic use and infection control practices aimed at reducing the spread of C. diff within healthcare settings.
Flu Vaccine Amongst Healthcare Workers
Influenza can spread quickly in healthcare environments and may be especially dangerous for patients with complex medical needs.
This measure reflects the percentage of healthcare workers who received a flu vaccination during the reporting period and supports efforts to reduce the risk of illness for patients, visitors, and staff.
Patient Falls with Major Injury
Patients recovering from serious illness may experience weakness, balance issues, or mobility limitations that increase their risk of falling.
This measure helps care teams monitor the occurrence of falls resulting in serious injuries and evaluate safety practices aimed at reducing harm while supporting patient mobility.
Activities of Daily Living & Thinking Skills Assessment
Understanding how patients function in their daily activities as well as how they process and respond to information, is an important part of planning care in a long-term acute care setting.
This measure reflects whether activities of daily living and thinking skills were assessed and whether related goals were included in the patient’s treatment plan, supporting coordinated and individualized care planning.
Functional Ability Assessment
Serious illness and extended recovery can impact a patient’s strength, endurance, and mobility affecting daily activities such as walking or bathing.
This measure helps teams evaluate whether functional abilities were assessed and whether goals to maintain or improve those abilities were incorporated into the treatment plan.
Supporting Mobility During Ventilator Recovery
Some patients are admitted while receiving mechanical ventilation which can limit mobility early in their hospital stay. As recovery progresses, safe movement and rehabilitation play an important role in overall healing.
This measure tracks changes in mobility over time for patients admitted on a ventilator and helps care teams evaluate how therapy, movement, and rehabilitation services support recovery during complex medical care.
Medication Review and Follow-Up
Medication regimens often change during hospitalization, especially for patients with multiple conditions.
This measure reflects whether medications were reviewed during the stay and whether appropriate follow-up care occurred when potential issues were identified, supporting patient safety and continuity of care.
Successful Return to Home or Community
For many patients and families, returning home or to a community setting is an important goal, though it may not be appropriate for everyone.
This measure helps describe discharge patterns at a population level and is used to understand transitions of care rather than predict individual outcomes.
How RML Uses Quality Data to Improve Care
RML regularly reviews quality and safety data as part of its commitment to continuous improvement. These measures help clinical teams understand trends, evaluate care processes, and identify opportunities to strengthen patient safety and outcomes.
Data is reviewed by multidisciplinary teams and used alongside clinical expertise, patient needs, and professional judgment. This approach supports thoughtful decision-making and ongoing improvement across all areas of care.
By sharing this information openly, RML reinforces its commitment to transparency, accountability, and high standards of care for every patient we serve.