Keeping Up - What's New

Dawn Myles, MS, MSN, RN
Senior Vice President, Quality and Patient Safety

Quality and Safety

Two important quality indicators for the network this year are reduction in Surgical Site Infection (SSI)-Colon and reduction in C-Difficile (C-Diff). This matches State and National focus areas, and both of these conditions impact our performance on the Medicare penalty payment program (along with CAUTI and CLABSI incidence, where we continue to hold our FY15 gains).

We have worked to ensure a network-wide, evidence-based, standardized implementation of best practice "Bundles" to reduce SSIs and C-Diff. First quarter network data show us lower than the national rate and performing better than goal year-to-date for C-Diff prevention. For Colon SSIs, case reviews and “bundle adherence” checking have been implemented. We will continue to pay attention to whether the cases are planned or emergent, as a higher number of emergent cases can lead to higher rates.

Full Root Cause Analyses have been conducted and action plans are being implemented for two Serious Safety Events (SSEs). Our goal this year regarding SSEs reflects a reduction from the prior year of already strong performance. We are on target year-to-date.

We continue to measure closely how satisfied our patients view their experience with us. In the first five months of FY16, all three inpatient locations, the medical group, and all three EDs achieved higher scores than in FY15. The EDs all met or surpassed their FY16 goals year-to-date.

We still have work to do on hardwiring the patient experience to produce scores consistently better than goal, but we are moving in the right direction. Multiple campus-specific and enterprise-wide activities are underway to drive continued positive movement.

We are closing out Phase One of our Network Policy and Procedure (P&P) Standardization project. This work produced great progress on standardizing policies and practices across the network. The project will bring improved access to policies, better policy management and governance, and a standardized approach to both new policy implementation and the revision of existing policies.

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