Quality Measurement
Quality Measurement
BayCare Clinic develops and measures a host of quality
indicators for each of the specialties that we serve. Quality
indicators fall into one of two categories: process or outcome.
Process quality indicators measure a BayCare
health professional's adherence to a process that is believed to be
of benefit to the patient.
Outcome quality indicators measure the actual
outcome of the patient's treatment plan, which may include
objective measures of result as well as patient satisfaction with
the services or results.
Below you will find a list of BayCare Clinic's quality
indicators, projects, and achievements listed by specialty.
All Specialties
Advance Care Planning: BayCare Clinic recognizes the right
of patient's to fully participate in health care decision
making. We offer patients the paperwork, and access to
assistance, to complete advance care plans.
BayCare Clinic has implemented
a Patient Feedback Register. This computerized database
allows BayCare Clinic staff to enter feedback, both positive and
negative, received from patients and their families. Feedback
from patients can be verbal, in writing, or sent over the
internet. Evaluating these comments in detail allows us to
benefit from each patient's experience. Managers and staff
can easily review comments to identify best practices, as well as
identify opportunities to improve clinical care, communication with
patients, or business practices involved in the total healthcare
experience.
Medication Management: This initiative strives to ensure patient
safety and optimal health care management. The process of
reviewing and documenting current medications with each patient
visit helps both patients and health care providers to:
Patient Education Tools: Prior to undergoing a procedure
that has associated risks, physicians work with patients to make
knowledgeable choices. In an effort to improve each patient's
ability to participate fully in making informed decisions, BayCare
Clinic is developing procedure specific patient education tools.
These tools, written in collaboration with the physician, describe
what will happen during the procedure, what it will look and feel
like, as well as what to expect during recovery. Risks,
benefits and alternatives to the procedure are also listed.
BayCare Clinic recognizes that healthcare visits are often
stressful times. We hope that by providing these easy-to-read
materials, patients can review details when they are best able to
think about options, and plan their care.
Anesthesia
Spinal Headache Post Labor Epidural: This measure helped
to identify the best practice in the treatment and prevention of
spinal headaches after labor.
Fertility Clinic Sedation: The study of quality indicators
during this procedure led to the development of a sedation protocol
which improved patient comfort and reduced the incidence of
post-procedure nausea.
Laparaoscopic Cholesystectomy
Patient Outcome Measurement: Standardization of best practice
resulting in decreased recovery time.
Prevention of anesthesia related surgical procedure delays or case
cancellations: This process outcome analyzes any delay or
cancellation in order to identity factors which will improve the
process for future patients.
Post operative pain management following Total Knee
Replacement: The Anesthesia department evaluated pain
management options to identify best practice for managing pain
following this surgery.
Cardiology
Standardization of physician order sets to best practice
protocols for Acute Myocardial Infarction (AMI) and Congestive
Heart Failure (CHF).
Francis G. Wolf, MD, William Witmer,
MD, and Ramon Ray G. Rayel, MD, received recognition from the
National Committee for Quality Assurance (NCQA-- for further
information please visit www.ncqa.org/hsrp) and the
American Heart Association/American Stroke Association's (AHA/ASA)
Heart/Stroke Recognition Program. This recognition is awarded to
Dr. Wolf, Dr. Witmer and Dr. Rayel for providing quality care to
their patients with cardiovascular disease or who have had a
stroke.
The Heart/Stroke Recognition Program
was designed to improve the quality of care that patients with
cardiovascular disease or who have had a stroke receive by
recognizing physicians who deliver quality cardiovascular and
stroke care, and by motivating other physicians to document and
improve their delivery of cardiovascular and stroke care. To
receive recognition, which is valid for three years, Dr. Wolf, Dr.
Witmer and Dr. Rayel submitted data that demonstrates performance
that meets the Program's key cardiovascular and stroke care
measures. These measures include blood pressure and
cholesterol control, among others. When people with
cardiovascular disease or who have had a stroke receive quality
care as outlined by these measures, they are less likely to suffer
additional complications, such as a second heart attack or
stroke.
Dr. Mathias, Dr. Witmer and Dr. Wolf have each been awarded
'star status' by United Health Care, one of the largest national
commercial insurance carriers. Physicians are eligible to
earn a quality star and efficiency star. The quality star
indicates that these physicians adhere to "nationally recognized
standards based on expert physician advice". The efficiency
star is awarded to physicians based on how efficiently they manage
an entire episode of care for each patient. The efficiency
star evaluates whether physicians perform unnecessary tests, manage
medications effectively, make appropriate referrals, etc.
Each of the BayCare Clinic cardiologists earned both the quality
and efficiency stars.
In addition the Cardiology physicians of BayCare Clinic
are crucial participants in managing the care of patients who have
had heart attacks and admit to Aurora BayCare Medical Center.
The Centers for Medicare and Medicaid Services publicizes data
about how well hospitals care for patients who experience heart
attacks. At the
www.hospitalcompare.hhs.gov website the public can view
hospital results. ABMC is among the top 10% of hospitals in
the nation, as rated by the Centers for Medicare and Medicaid
Services, in providing care to patients with heart
attack.
Cardiothoracic Surgery
Mortality; Length of Stay; Cost
BayCare Clinic Cardiothoracic surgeon, Dr. Alex Roitstein, has
consistently volunteered to submit data on processes and results
related to cardiothoracic surgery to the Centers for Medicare and
Medicaid Services. By participating in these programs Dr.
Roitstein demonstrates his commitment to assuring the public will
be able to access information that can help them select the doctor
best suited to meet their needs. Dr. Roitstein has also
earned the quality and efficiency star rating from United Health
Care.
Dr. Roitstein actively contributes data to the Society for
Thoracic Surgeons for review of quality as well as advancement of
the field for the benefit of all patients.
Ear, Nose &
Throat
The otolaryngologists are
participating in a study to evaluate the impact of ear tube
placement on the quality of life for patients and their
families.
In addition, the Ear, Nose & Throat physicians
volunteered, and are actively participating in a Medicare Program
evaluating the quality of care being provided in the outpatient
setting, the "Physician Quality Reporting Initiative".
Emergency Physicians
American College of Surgeons (ACS) Level II Trauma
Certification.
The Emergency Department physicians provide initial services to
many patients for heart attack, congestive heart failure, and
pneumonia. At the
www.hospitalcompare.hhs.gov website the public can view
hospital ratings in providing appropriate care to these
patients. For heart attack and pneumonia ABMC
ranks amongst the top 10% of hospitals in the nation. For
congestive heart failure, ABMC ranks amongst the top 20%.
The Emergency physicians have elected to participate in
Medicare's nationwide voluntary reporting program that measures the
care provided to patients with pneumonia, stroke, heart attack,
chest pain and syncope while in the Emergency Department.
General &
Vascular Surgery
Carotid Endarterectomy: Reduce complication rate based on
the development of best practice protocols.
American College of Surgeons (ACS) Level II Trauma
Certification.
Green Bay Eye Clinic
Care of Patient undergoing Cataract Surgery:
Establishment of evidence-based practice guidelines.
The ophthalmologists and
optometrist at Green Bay Eye Clinic have volunteered, and are
actively participating in a Medicare Program evaluating the quality
of care being provided in the outpatient setting, the "Physician
Quality Reporting Initiative".
Neurological
Surgeons
Anterior Cervical Fusions : Establishment of evidence
based best practice guidelines.
The BayCare Clinic
Neurosurgeons are gathering information about the impact of spinal
surgery on the patient's ability to perform activities of daily
living.
American College of Surgeons (ACS)
Level II Trauma Certification.
Spine: Morbidity, Mortality, Length of Stay, Cost.
Stroke: Morbidity, Mortality, Length of Stay, Cost.
Each of the BayCare Clinic Neurosurgeons have earned the United
Health Care quality star.
Neuropsychology
Credentialed ImPACT Consultant for Concussion
Management.
The neuropsychologist group is looking to evaluate access to
their services - determining if patients are able to get
appointments within a timeframe acceptable to them, and appropriate
for their condition. This group of specially trained
psychologists performs and provides expert testing that helps
referring physicians plan appropriate care. The BayCare
neuropsychologists have a formalized process to survey referring
providers. Referring providers are able to provide
information that ensures the neuropsychology group is providing the
type and quality of information that meets both the patient and the
referring provider's needs.
Orthopaedic Surgery & Sports
Medicine
Dr. Hennigan, Dr. Henry, Dr. Limoni, and Dr.
Schnaubelt and have each been awarded both the quality and
efficiency stars by United Health Care.
The Orthopedic surgeon group submits data on patients who
undergo hip or knee replacement to the Centers for Medicare and
Medicaid Services. Consumers can view results for Aurora
BayCare Medical Center, for these types of surgery, at
www.hospitalcompare.hhs.gov.
Rotator Cuff Surgery: Study was completed to evaluate the
physician and clinic services provided to patients undergoing
rotator cuff repair.
Total Knee Replacement: Study was completed to evaluate the
physician and inpatient services provided to patients undergoing
knee replacement. This study specifically focused on pain
management, meeting patient's discharge destination goals, and
reducing the risk of surgical complications.
The Orthopedic surgeons have volunteered, and are actively
participating in a Medicare Program evaluating the quality of care
being provided in the outpatient setting, the "Physician Quality
Reporting Initiative"
Interventional
Pain Management
These specialty physicians are
actively working toward achievement of the National Committee for
Quality Assurance Recogntion for the care provided to patients with
back pain.
Plastic
Surgery
The physicians of this group
participated in the national voluntary reporting initiative of the
Centers for Medicare and Medicaid Services. This project is
specifically looking at the care physician's provide to patients
with a current or past history of malignant melanoma.
The Plastic Surgeons are developing a measurement plan to
evaluate patient satisfaction following breast surgery.
Radiology
Development of patient education tools
to enhance patients' understanding of complex radiologic
procedures.
The Radiology group submits
information to Medicare's "Physician Quality Reporting Initiative"
to evaluate radiologist quality practices related to the diagnosis
of stroke and the placement of central venous catheters.
Physical Medicine &
Rehabilitation
These specialty physicians are
actively working toward achievement of the National Committee for
Quality Assurance Recogntion for the care provided to patients with
back pain.
Urological
Surgeons
Urinary Incontinence Rate after a Radical
Prostatectomy
Stone Passage
Rate/Percutaneous Nephrolithotomy (PCNL)
Incontinence Rate after Laser
Success Rate Ultrasound Post
Ureteroscopy
The Urology physicians volunteered, and are actively
participating in a Medicare Program evaluating the quality of care
being provided in the outpatient setting, the "Physician Quality
Reporting Initiative".
CLIA Recertification
Timothy J. Kennedy,
MD, FACS, is a Member of the Society for Pediatric Urology
Our Specialties
Explore Quality in our Specialties
- ALL SPECIALTIES
- Anesthesia
Anesthesia
BayCare Clinic’s anesthesiology specialists integrate pain management and anesthesia into one cohesive model of care. We know that effective pain management is about more than a short-term condition—it’s about improving long term patient outcomes. In other words, if you feel better, you heal better.
- Audiology
Audiology
Audiology is the diagnosis and treatment of hearing loss and balance problems. BayCare Clinic’s Audiology & Hearing Aid Center provides a full range of hearing tests and rehabilitation services, for patients of all ages. Get sound advice at BayCare Clinic.
- Cardiology
Cardiology
Follow your heart to award class care at BayCare Clinic. Our mission is to help people lead healthier lives through the prevention, diagnosis, and treatment of cardiovascular disease. We’re known throughout the region for our superior heart care and clinical outcomes.
Sub-Specialties: Interventional, Pediatric Cardiology, Medical Cardiology, Cardiac Imaging, Peripheral Vascular Medicine
- Cardiothoracic Surgery
Cardiothoracic Surgery
Our board certified cardiothoracic surgeon works closely with your primary care physician, cardiologist and/or pulmonologist to ensure the best care possible. We provide treatment for heart, esophagus or lung diseases.
- Cosmetic Services
Cosmetic Services
Bring out your best with the self-assurance that comes from loving how you look. BayCare Clinic offers a broad array of cosmetic services, all provided by board certified, specialty trained physicians. World-class cosmetic surgery is here in Green Bay.
- Ear, Nose & Throat
Ear, Nose & Throat
BayCare Clinic’s ear, nose and throat (ENT) physicians treat a wide range of head and neck disorders. Our cross-functional team includes specialists in tonsillectomy, allergy, infectious disease, hearing loss, speech therapy and audiology.
Sub-Specialties: Audiology
- Emergency Medicine
Emergency Medicine
Our emergency physicians staff Aurora BayCare Medical Center, the first U.S. hospital to be verified as an Emergency Center of Excellence. Patients see a board certified emergency physician within 15 minutes of arrival, far lower than the national average of 46 minutes. We’re setting the bar for emergency care in Northeast Wisconsin.
Sub-Specialties: Toxicology, Critical Care
- General & Vascular Surgery
General & Vascular Surgery
The General and Vascular Surgery department of BayCare Clinic provides general and specialized surgical treatment for a wide range of conditions. We treat common problems such as appendicitis and hernias as well as rare or complex conditions.
Sub-Specialties: Vascular Surgery
- Green Bay Eye Clinic
Green Bay Eye Clinic
Recognized as Northeast Wisconsin’s eye care leader, the Green Bay Eye Clinic offers a full range of ophthalmology services. That includes the state-of-the-art vision correction surgery as well as highly specialized pediatric care and cosmetic surgery.
Sub-Specialties: Corneal and External Disease, Cosmetic Surgery, Glaucoma, Oculoplastic Surgery, Pediatric Eye Care, Refractive Surgery (LASIK), Retina, Cataract, Contact Lens and Optical
- Green Bay Hand Center
Green Bay Hand Center
At the Green Bay Hand Center, our hand surgeons have specialized training for hand surgery and treatment. Common problems we address include numbness in hands, tingling fingers, tennis elbow, and ulnar nerve damage. Our hand surgeons also provide carpal tunnel surgery and other carpal tunnel treatment.
- Hyperbaric & Wound Care Management
Hyperbaric & Wound Care Management
Millions of Americans suffer from problem wounds. These can be frustrating, painful, and even life-threatening. BayCare Clinic’s wound care specialists use state-of-the art treatments to heal chronic wounds.
- Interventional Pain Management
Interventional Pain Management
Pain is the body’s way of telling you something is wrong, and it should never be ignored. Chronic pain can cause long-term complications if left untreated. Interventional pain specialists specialize in finding the source of your pain and then reducing it, or even relieving it completely. Don’t let pain affect your quality of life.
- Neurological Surgery
Neurological Surgery
Our board certified neurosurgeons work with a team of specialists to offer comprehensive care for conditions of the brain, spine and nerves. Their practice combines nearly 100 years of experience with leading edge medical technology.
Sub-Specialties: Spine Surgery
- Neuropsychology
Neuropsychology
Our neuropsychology team provides care to adults and pediatric patients and can assist with the assessment of dementia; ADHD and learning disabilities; concussions; and other changes in concentration, reasoning, memory and personality.
Sub-Specialties: Adult Neuropsychology, Pediatric Neuropsychology, Adolescent Neuropsychology
- Oral & Maxillofacial Surgery
Oral & Maxillofacial Surgery
Oral and maxillofacial surgery focuses on treating diseases, injuries, and birth defects that affect the jaw, mouth, teeth and facial structure. We provide wisdom teeth removal, dental implants, and treatments for oral cancer, sleep apnea, TMJ, and more. BayCare Clinic has the only oral surgery practice in the Green Bay region with an entire team of board certified surgeons.
- Orthopaedic Surgery & Sports Medicine
Orthopaedic Surgery & Sports Medicine
The Orthopedic & Sports Medicine Center is the leader in orthopedic firsts in the Green Bay area. We offer diagnosis, treatment and rehabilitation for people with bone, joint or connective tissue disorders. We locally pioneered the use of minimally invasive outpatient knee replacement and reverse total shoulder replacement—among several other regional “firsts.”
Sub-Specialties: Foot/Ankle, Shoulder/Elbow, Sports Medicine, Hand, Cartilage Restoration, Joint Replacement, Hip Arthroscopy, Knee Surgery
- Physical Medicine & Rehabilitation
Physical Medicine & Rehabilitation
It’s time to move. We specialize in rehabilitation, restoring function after you’ve gone through a serious illness, stroke, or injury. Our mission: improve mobility, decrease pain, and improve your quality of life.
- Plastic Surgery
Plastic Surgery
When you choose a plastic surgeon from BayCare Clinic, you can be confident you’re getting the highest trained, most qualified surgeon available. As part of our plastic surgery practice, we treat patients seeking reconstructive surgery, improved symmetry, or simply an enhanced appearance.
- Radiology
Radiology
BayCare Clinic Interventional Radiology is one of BayCare Clinic’s medical specialties providing high quality care. We provide care to patients throughout Northeast Wisconsin and Michigan’s Upper Peninsula including Green Bay, Appleton, and the Fox Cities.
- Urology
Urology
Our board certified urologists provide urology exams and treatment of conditions and diseases of the kidney, bladder, prostate and urinary tract.
Sub-Specialties: Pediatric Urology, Robotic Surgery
- Vascular Medicine
Vascular Medicine
From prevention to intervention, BayCare Clinic treats all heart and vascular conditions. The vascular medicine specialty focuses on problems involving the circulatory system, including arteries, veins, or the lymphatic systems. Keep the blood flowing.