Joint Commission Review
Performance Improvement:
The mission of St.Vincent Dunn 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 St.Vincent Dunn Hospital is to provide the framework and support to allow the leadership of St.Vincent Dunn Hospital to lead the staff in continuous quality improvement.
The Board of Governors, Medical Staff and the Administration of St.Vincent Dunn 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 St.Vincent Dunn 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 St.Vincent Dunn Hospital demonstrates that patient safety is a top priority in 3 ways:
- The Patient Safety Goals established by The Joint Commission have been a part of St.Vincent Dunn Hospital’s safety initiatives since 2003 when the The Joint Commission established specified patient safety goals. 2009 Patient Safety Goals Status Report
- 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.
St.Vincent Dunn 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. The survey is done in conjunction with Agency Healthcare Research & Quality (AHRQ). St.Vincent Dunn Hospital will participate in the 2010 survey.
St.Vincent Dunn Hospital is colaborating with the Indiana Patient Safety Center on the "STOP BSI" project. This initiative is aimed at reduction and prevention of bloodstream infections (BSI) associated with a centrally placed intraveneous line used for fluid and med administration.
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.