PIMC Semiannual Report- Quality January – June 2017

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Presentation transcript:

PIMC Semiannual Report- Quality January – June 2017

Quality Management System The Quality Management Plan describes the quality management system established by Peace Island Medical Center (PIMC) to achieve its quality and safety objectives and goals. The Plan describes the methodologies and practices by which quality and performance are measured, monitored, analyzed and continually improved to advance health outcomes and reduce risks for patients. The multidisciplinary Quality Management Committee provides the oversight and mechanisms to achieve objectives established in the Plan and reports to the community Governing Board to drive accountability. A small number of events can keep us from our goals. Intense review of each event is occurring to understand what happened and then implement changes to improve patient care.

Quality Measures and Performance The Quality Management Committee monitors process and outcome measures to maintain safe, high quality care and drive necessary improvement. Peace Island Medical Center has successfully met targets for key quality indicators, including but not limited to: Falls with Injury 30 Day Readmissions Hospital Acquired Pressure Injuries Patient flow (door to practitioner time) Healthcare-associated Infections Patient Experience – Inpatient Overall

Quality Measures and Performance (continued) Falls with Injury

Quality Measures and Performance (continued) 30 Day Readmission

Quality Measures and Performance (continued) Hospital Acquired Pressure Injuries

Quality Measures and Performance (continued) Patient Flow (door to practitioner time)

Regulatory Update In March and April 2017, Peace Island Medical Center underwent surveys by the accreditation agency, DNV, and the WA State Department of Health (DOH). Both surveying agencies reviewed systems and processes around the patient care, infection prevention, quality management, staffing, and the environment of care. Plans for improvement and mitigation measures were approved in April and May 2017 and improvement plans are on track or completed.

Recognition PIMC received a citation of merit from Premier QUEST for the second year in a row recognizing top performance nation-wide in multiple dimensions, including quality and patient safety.