Joint Commission Review
Performance Improvement:
The mission of Dunn Memorial Hospital is to provide quality healthcare that is patient focused with a commitment to the community we serve.
The mission of the performance improvement at Dunn Memorial Hospital is to provide the framework and support to allow the leadership of Dunn Memorial Hospital to lead the staff in continuous quality improvement.
The Board of Governors, Medical Staff and the Administration of Dunn Memorial Hospital are committed to a performance improvement plan designed to objectively and systematically measure and assess performance thereby improving patient health outcomes.
The Administration of Dunn Memorial Hospital will ensure quality patient care by requiring and supporting the establishment and maintenance of an effective hospital-wide Performance Improvement Plan. The plan encompasses and integrates the organization’s mission; the needs and expectations of patients, staff and others; and the performance of processes and outcomes within the organization. The plan shall examine processes and outcomes within the organization using a systematic measurement system that takes into account both internal and external data.
The Performance Improvement Plan encompasses all key functions of care and services provided. To improve the hospital performance as well as patient outcomes, concurrent and ongoing monitoring and evaluation of activities are conducted in these areas.
A multi-disciplinary task force conducts environmental and departmental walk-throughs to assess the facility and processes for safety and best practice. Patient records are reviewed using the “tracer” methodology established by the Joint Commission to review records and patient care in a comprehensive manner.
Culture of Safety:
Environmental and employee safety are followed closely by the Safety Committee. Monthly reports regarding injuries, equipment, safety checks, drills and educational opportunities are reported monthly to Safety Committee and deviations are addressed by the Committee for resolution. A quarterly Safety evaluation log is kept and updated for each calendar year and the repost submitted the safety Committee and the Buildings and Grounds Committee. This report logs the data collected in the process of improving our safety statistics and processes.
Patient and family-centered care is based on the culture of safety we are developing by striving for a non-punitive reporting process. When the reporting process is non-punitive, it encourages the employees to report safety issues in a more timely and thorough manner; thereby, allowing for increased safety of the patient and their family members.
The organizational leadership of Dunn Memorial Hospital demonstrates that patient safety is a top priority in 3 ways:
- The Patient Safety Goals established by the JCAHO have been a part of Dunn Memorial Hospital’s safety initiatives since 2003 when the JCAHO established specified patient safety goals.
- By developing the culture of safety with a non-punitive environment an increase in reporting is expected.
- The Patient Safety Initiative is the strategic quality initiative for PI/RM.
A “blame-free” environment is balanced with job performance. If an improvement process is identified as a result of a specific incident, an action plan will be designed. Failure to follow the designated action plan will result in an actionable objectives.
The Patient Safety Goals are incorporated into performance reviews for both employee and physician.
Patient safety goals and initiatives are:
- Identified through safety problems or incident reporting process
- Prioritized through severity and recurring issues
- ustained through investigative process and follow-up action plan and process
Risks and safety issues are identified though results presented to Safety Committee and through PI/RM reporting processes. Upon receiving deficiency reports or outcomes, processes are reviewed either by a PI process or root cause analysis. Changes are disseminated throughout the campus by safety notices, changes in policy are sent to all department managers for review with staff and special inservices as warranted by occurrences. Follow-up monitoring is noted by action plan and review of performance measures in forthcoming documentation or process outcome.
Dunn Memorial Hospital participates in an employee safety survey on a bi-annual basis through the Indiana Quality Improvement organization, Health Care Excel. The results will be posted on the Indiana Patient Safety Center website: www.indianapatientsafety.org.
Education is the key to sustaining process change. Reinforcement and follow-up may be necessary until the new or revised process is accepted practice.
Revenue Integrity:
Revenue Integrity works to ensure the accuracy of patient charges and to see that billing guidelines are followed.
Infection Control:
The purpose of the Infection Control Department is to develop and assist in implementing programs to prevent, identify, and control infections acquired in the hospital or brought into the hospital from the community. The Infection Control Department uses the Centers for Disease Control definitions for differentiating healthcare associated infections from community-acquired infections.
Hospital surveillance is utilized to detect and record all healthcare associated infections that occur throughout the hospital. The Infectious Disease Physician and Infection Control Practitioner are responsible for the follow-up of infection control concerns.
This department also has the responsibility to establish and enforce standard and isolation procedures for the protection of patients and personnel. The mandatory reporting of specific contagious diseases to the local and state health departments is accomplished through the Infection Control Department.
2007 Patient Safety Goals Status Report:
| GOAL | Status |
|---|---|
| 1 Patient Identification | |
| A. Improve the accuracy of patient identification - use at least 2 patient identifiers when providing care, treatment or services. | 2 identifiers are requested for each patient encounter that provides care and treatment to a patient. |
| 2 Improve the effectiveness of communication among caregivers. | |
| A. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result “read back” the complete order or test result. | Panic form implemented. Completed 2nd quarter 2007. |
| B. Standardize the list of abbreviations, acronyms and symbols that are not to be used throughout the organization. | Completed in 2005 |
| C. Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results | Completed in 2007 |
| E. Implement a standard approach to “hand off” communications, including an opportunity to ask and respond to questions. | Completed 4th quarter 2007 |
| 3. Improve the Safety of using Medications. | |
| B. Standardize and limit the number of drug concentrations available in the organization. | Completed 2006 |
| C Identify, and at a minimum, identify a list of look-a-like/sound a-like drug pairs used in the organization, and take action to prevent errors involving interchange of these drugs. | Completed 4th qu 2007. |
| D. Label all medications, medication containers, ( e.g., syringes, medicine cups, basins)or other solutions on and off the sterile field in peri-operative and other procedural settings. | Completed 4th qu 2007. |
| 7. Reduce the risk of health-care associated infections. | |
| A. Comply with CDC hand hygiene guidelines | Completed by Infection Control 2006. |
| B. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with heath-care associated infections. | Completed policy 2006. Additionally the 27 reportable never events established 2006. |
| 8. Accurately and completely reconcile medications across the continuum of care. | |
| A. There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. | Medication reconciliation completed early 2007. |
| B. A complete list of the patient’s medications is communicated to the next provider of service when a patient is transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge form the facility. | Completed 2006. |
| 9. Reduce the risk of patient harm resulting in falls. | |
| B. Implement a fall reduction program, and evaluate the effectiveness of the program | Implemented 2005. Revisions and updates to the program are ongoing. |
| 13. Encourage patients’ active involvement in their own care as a patient safety strategy. | |
| A. Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. | Completed 4th qu 2006. |
| 15. The organization identifies safety risk inherent in its patient population. | |
| A. The organization identifies patients at risk for suicide. Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals. | Completed 4th qu 2007. |
2008 Patient Safety Goals Status Report: Only additional goals added.
| GOAL | Status |
| 3 – Improving the safe use of medications | |
| NEW 3E: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. | There is a one year phase in w/ checks at 3, 6, 9 months in 2008.
1. In mid-2007 Pharmacy decreased number of concentrations. 2. Alerts used in medication administration system. |
| 16 – Improve the recognition and response to changes in a patient condition | |
| NEW 16A: The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening | There is a one year phase in w/ checks at 3,6,9 months in 2008.
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