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Quality and Outcomes

CHS and St. Catherine of Siena Medical Center leadership perform annual and ongoing review of Performance Improvement Program(PI) initiatives; set priorities, determine structure, develop scope and implementation, and assess effectiveness of the PIP. This process supports CHSLI’s mission of continuing Christ’s healing mission, promoting excellence in care and serving those in need. 

The PIP program is evaluated by The Board Performance Improvement Committee (BPIC), which is chaired by a Board of Trustee member. Membership includes board members, community representatives, medical staff leadership and administrative leaders. Together these dedicated members review Center for Medicare and Medicaid Services (CMS) publicly reported data, Institute of Healthcare Improvement(IHI) and The Joint Commission (TJC) priority projects and organization-wide activities including: Quality Dashboard; TJC National Patient Safety Goals (NPSG’s); Nursing Sensitive Indicators; Patient Flow and Occupancy Data; Ambulatory Care Quality Indicators; St. Catherine of Siena Nursing Home Quality Reports; Compliment and Complaint Data; NYPORTS (New York Patient Occurrence Reporting and Tracking System) and Root Cause Analyses (RCA).

Click to download SCS Quality Safety Sheet