“I would like to take this opportunity to announce important Patient Safety information about St. John’s Medical Center, in Jackson, WY. I also want to comment on the Leapfrog Group’s “Hospital Safety Scores” information published this week, for which St. John’s received a “C.” This grade in part reflects the fact that, due to our small size, we do not employ certain specialists or perform some procedures evaluated by Leapfrog Group; we thus are downgraded relative to major medical centers. The grade also in part reflects our early stage in the implementation of computerized support systems. Finally, the grade in part reflects Leapfrog’s use of past data that does not accurately reflect our current performance. While St. John’s has long provided quality care, we are committed to making continuing improvements in performance and it is important that patients make health decisions based on the best information available. I therefore would like to provide the community with an overview of our current quality and safety statistics. I also want to assure you that you have my continuing commitment to reporting our quality and safety statistics to the St. John’s Board of Trustees on a quarterly basis and to making that information fully available to patients on www.tetonhospital.org/quality .
Over the past year and a half, St. John’s Medical Center has strengthened our commitment to Quality/Patient Safety as a top organizational priority; our efforts are reaping tremendous benefits for patients. Our initiatives include a particular focus on continued improvement in the processes and outcomes indicators identified as most critical to quality patient care by the federal government’s Centers for Medicare and Medicaid Services (CMS). Like all other U.S. hospitals that accept Medicare and Medicaid patients, St. John’s Medical Center regularly submits data to CMS, which requires hospitals to demonstrate quality of care according to strictly defined standards. A description of some of our current initiatives and results follows this statement.
As indicated in the statistics at the end of my comments, St. John’s has achieved improvement and excellent performance on a number of national quality and patient safety measures. We also have areas for improvement, which we acknowledge and are addressing. Nonetheless, our achievements to date are beginning to be recognized by outside organizations. On September 27, 2012, for example, St. John’s Medical Center was awarded the Commitment to Quality Award by Mountain Pacific-Quality Health for outstanding performance in giving excellent care in the nationally measured areas of heart failure, pneumonia, acute myocardial infarction, infections prevention and surgical complications. We also have areas for improvement, which we acknowledge and are addressing. I appreciate the participation and support of the entire hospital and physician staff for helping us achieve such commendable results.
Lastly, I want to express my support for the work of national organizations that strive to help patients make educated healthcare decisions. There are many factors to consider when selecting a hospital, and quality and patient safety belong at the top of the list. I pledge my ongoing support for continued improvement at St. John’s Medical Center and strongly encourage community members to research current available data when making healthcare decisions for themselves and their families.”
St. John’s Medical Center Efforts and Current Results
Patient Safety and Quality Initiatives
• CPOE -- St. John’s has implemented computerized physician order entry (CPOE) for the majority of the medical staff; further roll out is in progress. CPOE helps ensure patient safety through the direct ordering of tests/medications and treatments through a computer system. CPOE has been 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 are in progress. Improvements have already been noted.
• Healthcare Safety Initiative -- St. John’s is participating in an on-going program that includes education and process improvements to reduce opportunities for error and to improve communications.
• Medication Reconciliation Process Improvements – These have been implemented throughout the organization.
• Hand Hygiene – St. John’s has achieved 88% compliance with hand washing goals 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%
The Joint Commission – ORYX (Core Measures) Performance Measure Report Accountability Composite Rate (Q2 2010 through Q1 2012) = 96.9%