1. Evaluate whether Jasper Medical Center's three quality improvement initiatives comply with applicable standards established by external agencies.

2. Evaluate how Jasper Medical Center's three quality improvement initiatives comply with the necessary federal and New York state legal requirements.

High-Quality Reliable Care (Current Process) To assess the quality of our care, we monitor both processes (how we deliver your care) and outcomes (the results of your care). For instance, one CMS-endorsed process measure focuses on how well we equip heart failure patients to continue their care once they return home. Considering this, we've focused on ensuring more thorough in-hospital education about the importance of consistently monitoring symptoms. Jasper medical center has access to a robust, real-time database that compares its quality outcomes with more than one hundred academic medical center peers.

Initiative 1: Rescuing Patients with Severe Sepsis/Septic Shock When a patient has an infection, sepsis may occur. Sepsis is an inflammatory response throughout the body caused by chemicals released into the bloodstream to fight the infection. Jasper medical center has joined state agencies in working to prevent mortality from severe sepsis and septic shock. In 2013, our teams of doctors and nurses developed best practice "bundles" to identify and treat adults and children with sepsis. These bundles were implemented in 2014, and since then, we have been collecting data to measure compliance with the best practices for each patient. These efforts have shown reduced mortality related to severe sepsis and septic shock.

Initiative 2: Reducing Avoidable Readmissions: Striving for Safe Transitions Readmissions place undue physical, emotional, and financial burdens on our most vulnerable patients. Still, national data show that one in five Medicare patients will wind up back in a hospital within 30 days. Eager to provide our patients with more effective caresafer, more seamless transitions back to their home or a skilled nursing facilityJasper medical center will continue an ambitious effort to improve the discharge experience. A key component of this effort involves identifying patients who are particularly at risk for readmission (for instance, patients who have been readmitted in the past or who have certain conditions like congestive heart failure or pneumonia), and then taking extra measures to support their discharges. The program empowers patients and families, providing more robust patient education about medicines (their unique purposes, potential side effects to watch for, etc.).