Quality Improvement

Patient Safety

Valley Regional Hospital is dedicated to pursuing quality-driven excellence for every patient, every time. Each aspect of your care is reviewed; from the time you enter our healthcare system through diagnosis, treatment, and recovery.

Excellence in patient care is a coordinated, collaborative effort and we believe that the best and safest patient care is achieved when patients and their loved ones are active participants. Our quality program uses a two-tiered approach to evaluate patient care: patient satisfaction and patient outcomes. We track patient satisfaction through formal surveys, inpatient rounding, and carefully listening to what our patients have to say.

In addition to satisfying our patients, we want to provide the best patient care based on evidence and research. In setting our quality goals, we follow standards set by national and regional organizations in healthcare. This year's goals include:

Patient Outcomes & Processes:

• Prevent infection through practices such as hand hygiene and cleaning and disinfecting patient care equipment
• Identify, manage and reduce your risk of a pressure ulcer
• Improve treatment of heart failure and pneumonia
• Reduce transfer time of patients requiring more specialized care
• Reduce risk of surgical site infections through careful antibiotic use

Safe and effective care for heart attack treatment include:

• Aspirin on arrival = 95%
• Betablockers on discharge = 100%
• Appropriate hypertensive medications = 100%
• Smoking Cessation Advice = 100%

Safe and effective care for heart failure treatment include:

• Appropriate hypertensive medications = 100%
• Patient discharge instructions = 72%
• Smoking Cessation Advice = 97%

Safe and effective care for pneumonia treatment include:

• Blood culture before first antibiotic dose = 93%
• Timeliness of antibiotic = 94%
• Pneumococcal vaccine = 97%
• Smoking Cessation Advice = 100%

The next set of quality measures is endorsed by the Center for Medicare and Medicaid Services (CMS) related to prevention of surgical infections. The recommended treatment, and the percentage of time we achieve the recommendation is below*:

Safe and effective care for surgical care patients include:

• Antibiotic one hour prior to surgery = 96%
• Selection of appropriate antibiotic = 97%
• Appropriate duration of antibiotic = 100%
• Medication given to prevent blood clots = 100%

Strategies for improvement, endorsed by national organizations, include the use of checklists, standardized order sets, and patient education material. We continue to examine and implement new strategies to reach our goal of achieving 100% compliance for all measures.

If you have questions or feedback, contact the Quality Improvement Department at (603) 542-1802.

*Data above represents all cases from 10/01/08 - 9/30/09