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Quality & Safety
The assurance of safe, quality care is fundamental to the vision of St. John's Medical Center. Meeting and exceeding the expectations of our patients and achieving best outcomes are central goals to which all employees at SJMC aspire.
To this end, SJMC continually monitors various indices of the care received by our patients. The SJMC Performance Improvement Plan, updated annually, strategically guides the collaborative staff effort to deliver high quality care. Senior leadership committees and the Board of Trustees oversee the organizational efforts.
St. John’s Medical Center Current Efforts and Results
Patient Safety and Quality Initiatives
Computerized Physician Order Entry – St. John’s has implemented Computerized Physician Order Entry (CPOE) for the majority of the medical staff; further roll out is in progress. CPOE provides for patient safety through MD direct ordering of tests/medications and treatments through the computer. Shown to reduce errors related to handwriting or transcription errors.
ICU Physician Staffing – The St. John’s ICU is covered 24/7 by employed hospitalist physicians.
Safety Culture – Employee Perception of Culture of Safety Assessment completed. Action Plans to increase reporting and address communications issues is in progress. Improvements have been noted.
Healthcare Safety Initiative – St. John’s is participating in an on-going with program from HPI that includes education and implementation or process improvement to reduce opportunity for error and to improve communication.
Medication Reconciliation Process Improvements – Organization wide
Hand Hygiene – 88% compliance with hand washing through the third quarter of 2012
Care of Ventilated Patient – St. John’s implemented bundle practices to prevent ventilator associated pneumonia. Zero cases in both 2011 and YTD 2012
Current Quality Core Measure Statistics
Patients received antibiotics with 1 hour of incision – YTD 2012 = 98.5%, up from 94%
Patients receiving right antibiotics – YTD 2012 = 99.3%, up from 99%
Antibiotic Discontinued within 24 hours – YTD 2012 = 97.1%, up from 92%
Urinary Catheter removal on day 1 or 2 – YTD 2012 = 97.1%, up from 94%
Surgery patients received treatment to prevent blood clots – YTD 2012 = 98.7%, up from 85%
What is Measured and Why?
Monthly tracking of measures include Core Measures, Patient Satisfaction and, Infection Rates.
Core Measures are specific data that are gathered from medical records. They measure precise areas for which care is rendered and received. Reviewing the SJMC Core Measures on a monthly basis and meeting best practice criteria assure that patients receive the safest, quality care. These measures include Community Acquired Pneumonia (CAP), Acute Myocardial Infarction (AMI), and the Surgical Care Improvement Project (SCIP).
Patient Satisfaction is information collected on surveys that patients receive after visiting St. John’s. This information is compiled by a third-party vendor and analyzed. The data are available for public use on public websites such as Hospital Compare (www.hospitalcompare.hhs.gov).
The provision of safe care through the infection prevention program is strategic to everyday practice at SJMC. The prevention of infection is a primary goal for all employees. Following guidelines from the Centers for Disease Control (CDC), hand hygiene is closely monitored. Ongoing education with the most up-to-date research for preventing infection and providing the safest patient care is a part of everyday life at SJMC. The Infection Control Specialist at SJMC is central to a vital infection prevention program in which all staff is required to participate.
SJMC is nationally accredited by The Joint Commission. This accreditation is granted to those organizations that demonstrate adherence to strict standards in areas such as Leadership, Performance Improvement, Safety, Environment, Infection Control, Medication Management, Emergency Management, and Rights of the Individual. SJMC most recently completed this tri-annual survey in the fall of 2011.