"Public Reporting" means disclosing, in report card style, how well we are doing.   It is our belief that transparency of performance will drive improvements, reduce medical errors, and increase the value of care we provide to our patients.  Improving the quality of care is a core mission of UNM Hospitals.  Sharing our performance data on a regular basis with our patients and their families is our way of demonstrating to you how we are achieving this goal.  We think these reports are essential to our community.

The information contained in this site will help you make sound healthcare decisions and provide peace of mind.  It provides data on key performance measures. Importantly, it details the numerous quality initiatives that UNMH is undertaking to further enhance and improve quality for our patients.

Hospital acquired infections (HAI) may cause a serious problem for patients.  While these infections are not always preventable or predictable, steps can be taken to reduce their likelihood.  UNMH has set a standard or goal to reduce as much as possible hospital acquired infections.

Our goal is to eliminate hospital-associated infections that arise 48 hours or later following admission to the hospital.  Infections can cause patients to remain in the hospital for a longer than expected period due to required treatment and management of the infection.  In certain severe situations, an infection can cause death.  As a result, at UNMH we have implemented a rigorous campaign to reduce the chance of acquiring hospital-associated infections.

To reduce the chance of infection, risk reduction programs to decrease infections associated with a hospitalization have been established.  These programs are based on recommendations of national agencies.  In keeping with the national agenda to make hospitalizations safer for patients, the UNMH has the following goals to reduce healthcare associated infections:

1. Reduce and eliminate healthcare associated central venous line associated bacteremias (CVLABS) or bloodstream infections
2. Reduce and eliminate healthcare associated ventilator associated pneumonias (VAPs)
3. Reduce and eliminate surgical site infections (SSIs) associated with a surgical procedure performed in an ambulatory or in-patient setting
4. Hand washing and infection reduction
5. Reducing infection through enhanced patient knowledge
6. Commitment to decrease new and emerging pathogens that impact hospitalized patients such as
• Methicillin Resistant Staphylococcus Aureus (MRSA)

UNMH's goal is to reduce and eliminate healthcare associated central line related bloodstream infections.

Central lines are used in patients in the intensive care unit and other in-patient and ambulatory settings to deliver medications.  A catheter is placed into a large vein usually in the upper portion of the chest area or at times in the area of the groin.  Although a central line is necessary at times for management of an illness or disease, it can lead to an infection.

Institute for Healthcare Improvement information on CVLABs

Adult ICUs and Pediatric ICU BSIs (2002-2007)

UNMH's goal is to reduce and eliminate healthcare associated pneumonias in people on mechanical ventilators.

Some hospitalized patients are placed on a machine, called a ventilator, to help them breathe.  When a patient is using a ventilator to help with breathing, they have an increased risk of acquiring an infection known as ventilator-associated pneumonia.  In 2006, the health system began a monitoring process to decrease these infections.  The facilities within the health system have demonstrated excellence in this area.

Institute for Healthcare Improvement information on VAPs

Adult ICUs and Pediatric ICU VAP (2002-2007)

UNMH Goals To reduce and eliminate surgical site infections associated with a surgical procedure performed in an ambulatory or in-patient setting.

In a majority of surgical procedures, the skin is cut to gain entry under the skin.  The cut, known as an incision, breaks our body's first line of defense against infection.  When there is a break in the body's defense, the risk for bacteria to enter the body and cause an infection increases.  UNMH is dedicated to minimizing the risk of infection associated with surgical procedures.  The following is a list of infection prevention measures that have been implemented and are monitored to ensure continuous improvement:

1. Administering antibiotics specific to the surgical procedure within 1 hour of the incision
2. Removal of hair at the surgical procedure site with a clipper when necessary
3. Keeping the sugar level in the blood at a certain range in cardiac procedures
4. Maintenance of body temperature for select procedures involving the large intestine/colon

Institute for Healthcare Improvement information on SSIs

UNMH's goal is to improve hand hygiene in an effort to reduce infections.  The most important measure to reduce the spread of infection is appropriate hand hygiene.  UNMH has a comprehensive approach to hand hygiene supported by leadership.  We have educated our employees, and provided alcohol based hand sanitizers and sinks with soap to ensure hand hygiene.  Visual reminders can be seen when you enter our facility.

UNMH has made hand hygiene a priority.  We ensure compliance with the Joint Commission's National Patient Safety Goal for hand hygiene.

Reducing infection through enhanced patient knowledge

The website for the NM Department of Health http://www.health.state.nm.us/ provides disease specific recommendations that affect the spread of disease.

Our goal is to eliminate transmission of infectious diseases through enhanced knowledge.   Many diseases can be transmitted from person to person in the hospital.  The more information and knowledge you have, the better prepared you will be to reduce infection.

Influenza, or the "flu," is seasonal.  The flu is caused by a virus that can cause mild to severe respiratory illness and may cause death in especially vulnerable patients, such as infants, the elderly, and those with certain chronic diseases.  Every year a new strain of flu is associated with illness, which is the reason for annual vaccination with the influenza vaccine.  Each hospital has an internal process to identify the need for vaccination.  Remember to receive this vaccination annually.

Fact sheet on the influenza vaccine

The pneumococcal vaccine is recommended for select high-risk individuals.  The facility has an internal process to identify the need for vaccination.

Fact sheet on the pneumococcal vaccine

Ensuring up to date vaccinations for the pediatric population served within our community is the best way to prevent infection.  UNMH is working to make sure all patients who come here for health care receive appropriate vaccines.

UNMH is committed to decreasing new and emerging pathogens that impact hospitalized patients.

Methicillin resistant Staphylococcus Aureus (MRSA) is Staphylococcus Aureus that is resistant to select antibiotics.  Staphylococcus Aureus, at times referred to as "staph," is a bacteria that frequently resides in the nose or on the skin of healthy and ill individuals.   Staphylococcus Aureus and Methicillin Resistant Staphylococcus Aureus can enter the skin through a cut or other parts of the body.  When this occurs, an infection may develop.

Controlling the spread of MRSA is a challenge to healthcare facilities.  UNMH understands the serious nature of these bacteria and has implemented strategies to minimize the spread.

Institute for Healthcare Improvement information on MRSA