Quality and Performance Monitoring

The goal at the Joseph M. Sanzari Children’s Hospital is to provide high-quality, efficient care with compassion for the individual needs of each patient.  We strive to provide the best outcomes for our patients.  To achieve this we use best medical practices based on research and follow proven models of patient and family centered care.  We strongly believe parents and families are the best source of information about the child and should have the opportunity to participate in the care and decision making process.

The Section of Quality and Safety provides oversight for all areas of the Children’s Hospital.  We work collaboratively within the Children’s Hospital and with other programs at HackensackUMC.

To achieve our aim of high-quality, efficient, compassionate care, we

  • Participate in external programs that allow us to compare our performance with other children’s hospitals
  • Participate in studies designed to identify best practices and allow us to share practices and procedures that result in the best outcomes for our patients.

Listed below are some of the processes and outcomes that we monitor in the Joseph M. Sanzari Children’s Hospital.  These allow us to assess our overall performance and improve the care we deliver to children and their families.

All areas of the Children’s Hospital:

  1. Patient satisfaction
  2. Falls
  3. Pressure ulcers
  4. Pain
  5. Catheter-associated blood stream infections
  6. Mortality

Blood and Marrow Transplantation:

  1. Percent of patients with appropriate assessment and documentation of acute graft-versus-host disease
  2. Percent of patient survival to day 100 after transplantation
  3. Percent of donors who receive a follow-up phone call assessment

Neonatal Intensive Care Unit:

  1. Preventing neonatal hypothermia
  2. Preventing chronic lung disease
  3. Preventing retinopathy of prematurity
  4. MRSA screening and prevention
  5. Incidence of catheter-associated blood stream infections (CA-BSI)
  6. Incidence of ventilator-associated pneumonia (VAP)
  7. Increase the number of babies receiving breast-milk feedings
  8. Mortality

Pediatric Intensive Care Unit:

  1. Incidence of catheter-associated blood stream infection (CA-BSI)
  2. Incidence of ventilator-associated pneumonia (VAP)
  3. Skin integrity and prevention of pressure ulcers
  4. Mortality
  5. Unplanned extubations
  6. MRSA screening and prevention

Acute Asthma Care:

  1. Patient and Family education through use of asthma-specific discharge and home-management instructions
  2. Initiation of inhaled corticosteroids at time of discharge
  3. Insure follow-up with a primary care provider within one week of discharge from the hospital
  4. Eligible patients placed on a weaning protocol

Pediatric Emergency Department:

  1. Unplanned returns to the Pediatric Emergency Department within 48 and 72 hours of discharge
  2. Unplanned returns to the Pediatric Emergency Department within 48 and 72 hours of discharge resulting in admission
  3. Patient satisfaction
  4. Left without being seen

Pediatric Hematology-Oncology/Reuten Clinic:

  1. Fast track
  2. Immunizations for BMT patients

Daily Accommodation Suite

  1. Medication reconciliation


  1. Unplanned cancellation of surgical procedures


  1. HbA1c measured within past three months
  2. Discharge instructions are diabetes-specific
  3. Nutrition consult completed for all patients meeting criteria


Section Chief
Kevin Slavin, M.D.

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