Our staff of 50 quality and patient safety specialists track more than 5,000 quality measures throughout our system to tell us where we're excelling and where we can improve.

All hospitals measure quality, but Catholic Health is the only healthcare system in Western New York that makes its quality data available directly to you and your family.

System-wide measures:


Women's health:

Adverse Events

Adverse events are events or errors that can cause unintentional harm to a patient as the result of medical intervention, rather than the underlying medical condition.

Most adverse events are preventable. Preventable events can result from poor communication, a lack of safeguards or checkpoints, or human error. Failure to follow recognized, evidence-based best practices or guidelines at the individual or system level can lead to an adverse event.

At Catholic Health, when an adverse event occurs, we fully investigate the occurrence and complete a root cause analysis (RCA) in order to determine the attributing factor(s). Findings may result in a change to a policy or procedure and/or education for our associates and providers.

2019 Target: Less than 0.13 significant events per 1,000 patient days.

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Patient Experience Overall Rating

Upon discharge from the hospital, a random selection of adult patients will be mailed a survey based on criteria set by the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ). The questions cover a variety of topics including: pain management, communication, cleanliness, quietness, responsiveness of staff, discharge planning, overall rating and willingness to recommend our hospitals. 

The Overall Rating percentage includes only those patients that rated Catholic Health hospitals a top score of 9 or 10 on a 0-10 scale.  A higher percentage is better. 

2019 Target: Rating of 70.0% or higher

*State average based on third quarter 2017 through second quarter 2018 encounters.

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Patient Falls

While hospitals take precautions in preventing patient falls, they can occur for a number of reasons. Patients may be disoriented or have a weakened gait. They might not use the call button to ask for assistance, or a call may not be responded to immediately.

Fall prevention is a serious concern for all hospitals. By identifying patients at high risk for falls, providing timely risk reduction strategies and rounding frequently to address patient needs, Catholic Health aims to reduce fall occurrences.

2019 Target: Less than 2.32 falls per 1,000 patient days.

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Hospital Acquired Pressure Injuries (Bed Sores)

The risk for pressure injuries increases when patients are unable to shift their weight or move around independently. Prolonged pressure on certain areas of the body – often the heel, back and elbows – reduces circulation and cuts the supply of oxygen and vital nutrients. 

Daily skin assessments, frequent patient repositioning, skin protection strategies and specialty beds have all helped to reduce the incidence of pressure injuries.

2019 Target: less than 2.07%.

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Central Line Infection Ratio (Catheter-Associated Bloodstream Infections)

A central line is an intravenous line/ tube that goes into a large vein in order to administer medications or withdraw blood.

Central line infections can be avoided by maintaining a sterile environment and frequent oversight to ensure the line remains clean and protected.

We have implemented evidence-based practices (also known as the Institute for Healthcare Improvement (IHI) Central Line Bundle) in order to reduce the risk of infection. Components of the Central Line Bundle include, but are not limited to, proper hand hygiene, sterile technique and daily assessment.   

2019 Target Ratio: 0.549

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30-Day Readmissions (All Causes)

30-day readmissions occur when a patient returns to the hospital soon after their previous stay. Better quality of care, thorough communication to the next transition of care and patient compliance with doctor instructions all can reduce the risk of a hospital readmission. 

2019 Target: 10.18%

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Emergency Care

Catholic Health sees over 100,000 patients each year in its network of Western New York Emergency Departments.

Median Time from Admit Decision to Emergency Department Departure for Admitted Patients


*State median time based on calendar year 2018 encounters.

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Additional Resources

External reports from trusted sources demonstrate how we compare to other healthcare providers in Western New York and across the country.

  • Hospital Compare - government website with quality data for over 4,000 Medicare-certified hospitals.
  • Joint Commission - accredits / certifies hospitals nationwide
    Report a Patient Safety Concern or Event
    Do you have a patient safety event or concern about a health care organization?
    Electronic Submission:
    • https://www.jointcommission.org/report_a_complaint.aspx
    • Phone: 800-994-6610
    • Fax: 630-792-5636
    • Mail: Office of Quality and Patient Safety
      The Joint Commission
      One Renaissance Boulevard
      Oakbrook Terrace, IL 60181
  • The Leapfrog Group - allows you to search by city, state or hospital to see overall patient safety scores and scores for specific treatments, such as heart attack and weight loss surgery.