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Washington Hospital Quality Report Highlights Quality Initiatives and Tracks Hospitalís Performance

June 29, 2010

Most people who go to a hospital for treatment are at a vulnerable time in their lives, trusting that they will receive the highest level of care and experience the best possible recovery. As you consider the hospitals available to care for you and your family, how can you know which offers the best quality?

At Washington Hospital, our quest for quality has and always will be among our top priorities. Never satisfied with the status quo, we constantly look for ways to raise the bar on quality care and safety for our patients. Each year, as part of a continuing process, Washington Hospital’s Quality Steering Council, made up of representatives from the Board of Directors, Hospital senior leadership, and leaders of the medical staff, sets our direction. The Council reviews past achievements and challenges and also identifies a set of Established Goals to guide the Hospital for the coming year.

As part of its emphasis on quality, Washington Hospital publishes an Annual Quality Report to the Community. Washington issued its first Quality Report last year, and the second issue reports on its efforts to improve quality and safety during 2009. The 2010 Quality Report contains charts and graphs, giving you a better understanding of the Hospital’s safety and quality efforts.

Tracking Our Core Measure Performance
Washington Hospital continuously monitors and analyzes our performance related to Core Measures set by the Joint Commission and the Center for Medicare and Medicaid Services (CMS). For the past nine years, these organizations have monitored hospital performance related to proven therapies for conditions that contribute to a majority of U.S. hospitalizations. Each measure tracks a combination of evidence-based procedures that, when consistently implemented, have been shown to reduce the risk of complications and recurrences.

Hospitals track their compliance data and convert them into percentages, which can then be used to track improvement efforts and compare them with the performance of other hospitals. In turn, these results can be communicated to the general public to help people make decisions about their preferred hospital. The goal is for hospitals to be 100 percent compliant with all quality indicators.

In the complex hospital setting, achieving 100 percent compliance – which means doing the same thing for the same condition every time – can be a huge challenge. It takes teamwork and dedication by everyone involved in the care process, including frontline caregivers, hospital managers and administrators. Physicians are also key players in quality improvement efforts. Their participation in and support of evidence-based care is essential to achieving the best possible outcomes for patients.

What is Washington Hospital doing about quality?
Washington Hospital submits quarterly data on its performance related to a range of medical conditions and surgical procedures. Compiling and communicating this information is just one aspect of the Hospital’s ongoing, comprehensive quality improvement strategy, which is led by its Quality Steering Council. In addition, the Hospital collaborates with other leading quality organizations, including The Joint Commission, the Institute for Healthcare Improvement (IHI) and the Beacon Collaborative to develop, implement and track additional quality indicators that contribute to safe, high quality care.

It is Washington Hospital’s goal to consistently meet or exceed national and state benchmarks set by leading quality improvement organizations, including Core Measures developed by The Joint Commission. Historically, the Hospital has nearly always achieved this objective, often scoring 95 percent or higher. According to CMS, hospitals scoring in this range are in the top 10 percent nationwide and their methods related to that particular indicator are recognized as "best practices."

Fighting hospital-acquired infections
As part of its quality improvement program, Washington Hospital places a major focus on reducing all types of hospital-acquired infections. Among other strategies, it has employed evidence-based procedures to dramatically reduce the incidence of methicillin-resistant staphylococcus aureus (MRSA) infections, ventilator-associated pneumonia and post-operative infection. (See charts.)

Fighting severe sepsis
The Hospital was an early participant in the battle to save more lives from severe sepsis, a widespread, uncontrolled infection in the body. It developed an evidence-based sepsis initiative which has now been extended into all patient care areas. A multidisciplinary Sepsis Team continues working to improve processes for identifying, treating and managing sepsis patients. (See chart.)

Learn More About Washington’s Quality Initiatives
You can learn more about these and many other quality and safety initiatives at Washington Hospital by visiting its Web site at www.whhs.com/quality. The Hospital has also developed a Dashboard of Quality Indicators, which are reported to the Washington Township Health Care District Board of Directors on a quarterly basis. Monthly Board meetings are broadcast on Washington Hospital’s InHealth cable TV channel on Comcast 78. Information about the Hospital’s quality and safety initiatives is also available in its 2010 Annual Quality Report to the Community. You can obtain a free copy by calling the Hospital’s Community Relations Department at (510) 791-3417.

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