Quality and Safety

What is quality?

While quality can mean different things to different people, hospitals mean specific things when they talk about quality. To hospitals, quality refers to “clinical outcomes” or results.  When we talk about quality, we are talking about things we do that give our patients good outcomes, and what else we can do to improve our patients’ results.

How we achieve quality

While hospital quality measurements can be complicated, it is important to know how your hospital measures up. All together, these quality measurements paint a picture of the kind of care you can expect to receive while you are in the hospital. 

At HackensackUMC, you can be certain that in addition to expert physicians and highly skilled staff, you will have access to the most current treatments, procedures, and medications available. And, you can be assured that we are always dedicated to providing the highest-quality care.


One important way you can tell if you are getting high-quality care is by looking at the volume of procedures done in the facility. That’s because the more times a procedure is done, the more expertise your physicians have. Of course, outcomes are important too. It is a good idea to see a doctor who has lots of experience with your particular problem. It is also a good idea to choose a medical center that has the latest technology, highly-trained staff, and a culture of collaboration.

We never stop improving our quality

When we talk about improving quality, we are talking about the things we do that make a medical difference in the lives of our patients. There are certain key quality measurements that the government and accrediting agencies require us to track. But we go far beyond that. In regular team meetings with staff from many different departments, we look at various parts of our program and find opportunities to improve on what is already good. We also follow patients long after their discharge to make sure that their outstanding outcomes are lasting ones. And we encourage our patients to tell us what they think. This information is used to enhance the patient experience and expand what we offer to our patients so we can make sure we are meeting their needs.

Quality and you

How quality affects you

Before you decide to have surgery at a hospital, it is a good idea to know something about the quality of care at that hospital. Here are some questions you can ask about quality:

  • How many times have you done this procedure?

  • How often is this procedure done in this hospital?

  • Does this facility follow evidence-based processes of care?

  • Do you report your results to CMS (Centers for Medicare and Medicaid Services)?

  • How do your results compare with national averages?

  • What are the infection rates for this procedure in the last 2 years? 

  • Have the infection rates gone up or down in the last 6 months?

We are sure that the answers you receive answers to these—and any other questions you might have will give you confidence in the care you receive by our surgeons at HackensackUMC. When you choose to have your surgery at HackensackUMC, you are putting yourself in the care of a world-class team that is dedicated to providing you with the best possible care for your condition at all times.

You can help improve quality

You can also play a part in improving quality. It’s our job to keep you safe, but you can take an active role by following these 5 steps:

1. If you think something is wrong, say so.

2. If you are not sure about anything, ask questions. If you don’t understand the answer, keep asking.

3. Make sure you understand what will happen if you need surgery. Talk to all your doctors—the surgeon, anesthesiologist, nurses. Tell them about any allergies or any concerns you have.

4. Before you go for your procedure, make sure the nurses and staff have the right information about you and the procedure.

5. Let your doctor or nurse know if you are worried about falling. 

Hackensack University Medical Center is pleased to announce that it has been recognized by The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) as one of 52 ACS NSQIP participating hospitals that have achieved meritorious outcomes for surgical patient care.  As a participant in ACS NSQIP, HackensackUMC is required to track the outcomes of inpatient and outpatient surgical procedures and collect data that directs patient safety and the quality of surgical care improvements.   

The ACS NSQIP recognition program commends a select group of hospitals for achieving meritorious outcome performances related to patient management in several clinical areas, including mortality, unplanned intubation, cardiac incidents, and surgical site infections.  The hospitals were commended based on their outstanding composite quality score.  ACS NSQIP is the only nationally validated quality improvement program that measures and enhances the care of surgical patients. This program measures the actual surgical results 30 days postoperatively as well as risk adjusts patient characteristics to compensate for differences among patient populations and acuity levels.  


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