We Measure Our Performance

Ongoing quality measurement allows us to:

  • Ensure that medical record documentation is complete, thorough and accurate
  • Examine outcomes and processes
  • Identify opportunities to improve procedures and patient outcomes
  • Target educational programs to sites and providers for a positive, continuous feedback loop
  • Incentivize providers on those same quality metrics

Patient satisfaction, OR efficiency, practitioner performance and critical quality indicators are areas we carefully evaluate for continuous improvement in quality of care and service.

Examples by Specialty

Click on a specialty to view more details.


2012 quality metrics are as follows:

  • Surgical Care Improvement – Adherence to SCIP protocols
  • Processes of Care – Sleep apnea screening, remote anesthesia protocols, and airway assessment
  • Clinical Indicator Tracking and Occurrence Reporting – ASA Screening Recommendations (cAre Tool)
  • National Patient Safety Goals – Compliance with national patient safety goals, surgical time outs and anesthesia plans for each procedure
  • Efficiency Metrics – Tracking inpatient surgical readiness, surgery end to out time and case cancellation rates
  • Surgeon Satisfaction – Annual satisfaction surveys distributed annually
  • Patient Satisfaction – Monitoring in collaboration with client hospitals to provide an optimal patient experience
  • Data Warehousing & Reporting – Monitoring trends to identify opportunities for improvement initiatives

2012 Ambulatory Surgery quality metrics are as follows:
Adoption of the WHO Surgical Safety Checklist Compliance with Hospital Outpatient Prospective Payment System HOPPS for Centers for Medicare and Medicaid Services CMS Monitoring of Antibiotic Timing

Clinical indicators and outcomes collected through our Care Tool Program for Ambulatory Surgery Center reporting: Patient Burn Patient Fall Wrong Site, Side, Patient, Procedure, Implant Hospital Admission/Transfer Prophylactic IV Antibiotic Timing Safe Surgery Checklist Use Volume of Certain Procedures Influenza Vaccination Among Healthcare Workers

Emergency Medicine

2011 quality metrics are as follows:

  • We participate in CMS PQRS measures, reporting on more than 90% of our cases that meet CMS reporting criteria
  • LWBS, 2011 Monthly Average – .03%
  • For 2011, we have met 100% of our core measures, including Pneumonia (Door to Antibiotic) and Acute AMI
  • We meet 100% of our client partner throughput reporting metrics

Women's and Childen's

2012 quality metrics are as follows:

  • Each physician must achieve minimum score of 88% on chart audit
  • Metrics for each unit
    – Criteria Benchmarked against Vermont-Oxford Network Data
    – Survival by Gestational Age
    – Incidence of Chronic Lung Disease
    – Intra-Ventricular Hemorrhage Grade 3 and 4
    – Retinopathy of Prematurity Stage 3 and 4
    – Extra-Uterine Growth Retardation (EUGR)
    – Weight: 52.3%
    – Extra-Uterine Growth Retardation (EUGR) – Head Circumference: 28.3%
    – Necrotizing Enterocolitis Bell Stage 2 and 3 Chronic Lung Disease: <20%
    – Average Daily Weight Gain: 15gm/kg/day or better
    – Central Line Utilization in Infants <1500 grams: Less than 20%
    – Central Line Associated Blood Stream Infection (CLABSI): 0%


We monitor daily our turnaround time in both preliminary and final reads. Sheridan's average for discrepancy rates for preliminary rates is well below the national average.

Performance Focus Areas Include:

  • Clinical Care Core Competencies (Process of Care)
  • Physician Peer Review and Ongoing Professional Practice Evaluation (OPPE)
  • National patient safety goals (The Joint Commission)
  • Medical staff satisfaction
  • Monitoring, tracking and clinical trending
  • Data warehousing and reporting
  • FRESH – Final Results Electronically from Sheridan Healthcare
  • Turnaround times and length of stay (LOS) reduction

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