Quality Care: It’s a Department at Memorial Hospital
To ensure that all patients at Memorial Hospital receive the quality health care they deserve, we have a department dedicated to ensuring that hospital care meets the highest set standards. The Quality Department, which is led by Ann Smith, R.N., M.P.H., C.I.C., view, record and analyze data from virtually every patient encounter with a Memorial Hospital provided service. Hospital data is collected through chart analysis, daily rounding, process documentation and many other means.
Ann recently told me that the quality team at Memorial touches virtually every facet of the hospital’s services; they monitor everything from hand hygiene to renovation projects to medication administration to see that best practices are followed and properly documented.
The role of the quality department is essential as the hospital meets standards set forth by the Joint Commission, Ohio Department of Health, Ohio Hospital Association and other state and national organizations. Hospital data is also reported to many third party payers; the data can affect reimbursement.
Although quality may seem like an abstract concept to quantify, Memorial’s comprehensive analysis of hospital data provides associates with evidence-based conclusions in regards to which practices have the best results. The results are also used by outside agencies when determining accreditation and licensure status.
Quality Department: Points of Pride
- Percentage of patient with antibiotic received at least one hour before surgery has increased from 75% in Q1 2010 to 94.9% in Q1 2012.
- Blood cultures completed within required time frame improved from 33% in Q2 2009 to 100% in Q1 2012.
- Medication reconciliation compliance improved from 60% in July ’11 to 90% in December ’11.
- Correct post-surgical antibiotic timing improved from 50% compliance in Feb. ’10 to 92% compliance in Sept. ’11.
The quality department also compares Memorial’s statistics to statistics of hospitals nationwide, most of which are publicly reported. Quality data is used to develop and implement patient care policies; determine appropriate infection control processes; and ensure that Memorial Hospital meets national patient safety goals.
Ann explained to me that when analyzing our data, the Quality Department looks at why Memorial has had success in certain areas, as well as where there are opportunities for improvement, in the context of nationally comparable standards. This is the information is used to determine what performance improvement projects are necessary at Memorial.
The Memorial Hospital Quality Department has three full-time associates
Ann Smith leads the department. Andrea Cropcho, R.N., M.P.H., C.I.C. is the department's part-time infection control practitioner. Andrea makes rounds to monitor that proper day-to-day infection prevention processes are in place, and completes surveillance for hospital acquired infections. Deb Elder, R.N. is the quality coordinator. Deb reviews charts and other documentation to ensure that processes are meeting CORE and SCIP measures, and are in compliance with Joint Commission regulations. Erica Chapin, R.H.I.T. is the data analyst. Erica enters and analyzes department data; she also is the MIDAS system manager and will be integral to building the MIDAS system, which will change the way data is collected and analyzed at Memorial. MIDAS will ensure reliability, validity and immediate availability of hospital data at all time.
Hospital quality data is available online at hospitalcompare.hhs.gov, odh.ohio.gov and anthem.com.
Photo: From L to R: Erica Chapin, Andrea Cropcho, Deb Elder and Ann Smith
About the Author:
Chasity O’Neill has been with Memorial Hospital since 2008. She came to the hospital from The University of Toledo, where she worked as a director of development. She also previously work for the Medical College of Ohio Foundation as their director of annual giving. Chasity is a graduate of The University of Toledo with a Bachelor of Arts in Communication.
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