Page 2 - Sharon Hospital

2q life and health
By Denise Fink, RN, MPH
Chief Quality O cer, Sharon Hospital
ANNUAL REPORT
2 0 1 1 Q U A L I T Y R E P O R T
Awards
In 2011 we achieved these Get
With The Guidelines designations:
w Gold for heart failure care.
w Gold Plus for stroke
care.
We also received:
w Excellence in Emer-
gency Medicine for
EMPACS.
w TravelingTrophy
for quarter 4 fromRegionalCare
Hospital Partners for Highest Qual-
ity Outpatient Satisfaction among
7 sister hospitals.
For more information about our focus on quality, call 860.364.4228.
A t Sharon Hospital, our
organizational goals are
centered on the pillars of
quality, service, growth,
people, and nance. Each department
also sets its own goals to improve
processes or outcomes. When our
goals align, we are all focusing in the
same direction and making changes
that improve the entire organization.
We work as a team to improve our
processes and outcomes year-round.
Whether those processes involve set-
ting up new services—such as Wound
Care, the Pain Clinic or the Sleep
Center—or improving the e ciency
or outcomes of an existing service—
such as decreasing the wait time in
our Emergency Department—we fol-
low a time-tested method of produc-
ing change.
Using the plan, do, check, act
(PDCA) method of process improve-
ment, we rst establish teams com-
posed of people closest to the process
to formulate a plan. We then try our
ideas on a small scale, reassess the
plan and only then make changes
organizationwide.
We continually work to improve
in our core measures, which are sets
of evidence-based activities that have
proven over time to improve patient
outcomes. In 2011, the four main
core measures were:
w Acute myocardial infarction: We
achieved 90 percent perfect care
compliance.
w Congestive heart failure: We
achieved 89 percent perfect care
compliance.
w Community-acquired pneumonia:
We achieved 92 percent perfect care
compliance.
w Surgical care infection preven-
tion: We achieved 80 percent perfect
care compliance.
Perfect care is our goal. It means
that a patient received every recom-
mended, proven aspect of care for his
or her speci c disease.
Another major focus in 2011 was
potentially preventable hospital-
acquired conditions. Some of those
potentially preventable conditions
include:
w Pressure ulcers. By focusing e orts
on skin integrity issues, we had only
two hospital-acquired pressure ulcers
in 2011. Assessments, preventive
measures and interdisciplinary com-
munication have improved awareness
and prevention of hospital-acquired
skin breakdown.
w Urinary tract infections. Ongoing
education and increased awareness
and surveillance have led to a de-
crease from previous years: In 2011,
we had only six of these infections.
w Deep vein thrombosis (DVT).
ere was one case of hospital-ac-
quired DVT in 2011.
w Hospital-acquired pneumonias.
ere were 11 cases of hospital-ac-
quired pneumonia in 2011.
w Ventilator-associated pneumonia.
ere were no incidences of ventila-
tor-associated pneumonia in 2011.
w Central line infections. ere were
no central line infections in 2011.
w Methicillin-resistant Staphylococ-
cus aureus (MRSA). MRSA is a type
of staph bacteria that does not re-
spond to some antibiotics. ere was
one case of hospital-acquired MRSA
in 2011.
As we continue to assess the care
we provide, we, along with the pub-
lic, are able to compare ourselves to
surrounding hospitals both in the
state and region. We are proud to be
ranked among the best hospitals in the
state. We welcome you to compare our
scores on hospitalcompare.hhs.gov.
Public report cards are the way of
the future. We realize patients and
their families have a choice as to where
they seek health care. We are proud
of our outcomes and promise to do
all we can to continually improve our
services to our community.