Quality & Safety

Our commitment to quality defines who we are . . .

Patient Experience

When choosing a hospital, high marks for patient satisfaction should be among the most important considerations. In measuring the quality of care and service, we turn to the people who know best: our patients. For nearly ten years, we have been collecting extensive survey data rating the following:  

  • Teamwork
  • Responsiveness
  • Communication
  • Coordination
  • Confidence in caregivers
  • Courtesy/Sensitivity
  • Cleanliness
  • Overall satisfaction

One source we use to collect information on patients' perspectives of the care they received while in the hospital is the Hospital Consumer Assessments of Healthcare Providers and Systems (HCAHPS) survey, developed by the Centers for Medicare & Medicaid Services (CMS). In it, patients are asked about their recent overnight visit.  Your opinion of the experience you have with us is very important and we would welcome your feedback. Please take a few minutes to share your thoughts to assist us in improving the care we provide.

How & Why We Measure Our Performance

Maui Memorial Medical Center is committed to building a "culture of service excellence."  Our employees strive every day to ensure that our patients and their families receive safe and effective care by regularly monitoring performance that allow us to see where we're hitting the mark, and where we may need improvement.  By utilizing these performance reports based on your input, we are able to make informed and timely decisions that translate to better patient safety and outcomes.

Our mission to is to deliver the highest quality, safest, most innovative and compassionate care at all levels and we consider you a partner in this mission.  For this reason, we provide public access to internal and independent performance reports and quality scores throughout our hosptial, so our patients can participate in helping MMMC continually work to improve.  

Who measures performance?

Our team of quality assurance experts continually monitors and measures performance for Maui Memorial Medical Center. We evaluate and survey patients and staff at all levels to create hospital "scorecards." We also rely on reporting from national agencies such as the U.S. Department of Health and Human Services and The Joint Commission to tell us how we're doing.  We use a variety of methods to collect data and look to studies done by independent agencies to rate patient safety, clinical quality, areas of expertise, use of technology, patient satisfaction, fiscal responsibility, adherence to national standards of practice, patient outcomes, and more.

How does data help improve safety and quality?

Performance reports and scores are circulated to leadership, physicians, nurses, administrators, and other key staff members so they can monitor progress and communicate with their teams to drive where and how improvements can be made. This data also drives the evolution of system-wide policies and day-to-day operations related to patient care and safety.

Who can view reports?

When it comes to performance data, our policy is complete transparency. That means, regardless of how we score or what the numbers say, we'll share our reports and statistics.

The most recent information is available on the Centers for Medicare & Medicaid Services' Hospital Compare web site:  www.hospitalcompare.hhs.gov.

Clinical Measures

We measure our clinical performance through standardized benchmarks.  These clinical measures are a national standard of care related to a disease or process of patient care. The Centers for Medicare & Medicaid Services (CMS), American Heart Association and the Joint Commission designed and standardized these measurement areas.  Clinical measures serve as the foundation for the hosptial's quality initiatives.  Measures are based on scientific evidence and can reflect guidelines, standards of care, or practice parameters. A quality measure converts medical information from patient records into a rate or percentage that allows facilities to assess their performance.  Quality measures are used in other CMS hospital quality initiatives such as the Premier Hospital Quality Incentive Demonstration. The core measures reported by MMMC are:

  • Acute Myocardial Infarction (AMI)
  • Heart Failure (HF)
  • Surgical Care Improvement Project (SCIP)
  • Community Acquired Pneumonia (CAP)
  • Stroke

Congratulations MMMC for earning the Gold Plus Award for Stroke Core Measures!