Healthcare today is an extremely complex process and we know that it is sometimes imperfect. Incidence of harm in healthcare is a national concern. At GBMC, we believe that our patients have a right to know how we are doing and that we have made a commitment to be transparent and open about our efforts to provide safe and reliable care. Included on this website are many of the metrics we monitor such as hand hygiene, infections, patient satisfaction and quality care measures. Click on the name of the metric to learn more about what it is and see our most current measurements.
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) rating is a standardized survey and data collection methodology for measuring patients’ perspectives on hospital care. The survey contains 21 patient perspectives on care and patient rating items that encompass eight key topics, which include communication with doctors, responsiveness of staff, pain management and discharge information.
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is important to GBMC because it helps us identify how well we are performing in a number of areas. Eight categories that span the patient experience are measured and 21 questions are asked that provide an overall rating of the hospital.
GBMC uses this feedback from completed surveys to improve our patients’ experiences. For example, last year we identified nurse communication as an area to improve. A comprehensive action plan around hourly rounding was formulated and organization-wide training for standards of communication were implemented to drive improvement in this key domain. All staff, not just nurses and physicians, have been trained on these standards of communication. This is just one of the ways we’ve used HCAHPS feedback to improve the patient experience.
For patients who would like to see GBMC’s scores and compare them to other hospitals, they're available on www.hospitalcompare.hhs.gov. Patients are encouraged to view scores of local hospitals and use this as a factor in choosing where they receive their care.
Catheter Associated Urinary Tract Infections: A Catheter Associated Urinary Tract Infection (CAUTI) is an infection of the urinary system, including the bladder and kidney that occurs in patients using a catheter, a tube inserted into the bladder through the urethra to drain urine.
CAUTI's account for about 35 percent of hospital acquired infections. GBMC is diligent in its efforts to prevent CAUTI. There are checklists available that help care providers with both the insertion and maintenance of the catheter to help prevent infection.
There are also educational efforts for both the patients and clinicians on catheters and CAUTI. Patients receive education from their clinician prior to insertion to learn about why they have the catheter and the risks associated with it. Clinicians are also re-educated periodically about proper insertion and maintenance of the catheter. They also work diligently to get the catheter out as soon as it is no longer medically necessary.
Hand hygiene plays an important role in preventing CAUTI. Patients are encouraged to ask their care providers if they’ve washed their hands.
CAUTI can cause patients severe discomfort, frequent urination and the overwhelming urge to urinate. Some of the bacteria that cause CAUTIs are becoming resistant to commonly used antibiotics and that decreases the choices for treatment. They may reduce immunity and in severe cases, may spread to the kidneys.
Central Line Associated Blood Stream Infections (all hospital)
A Central Line Associated Blood Stream Infection (CLABSI) is a serious infection that occurs when germs cause a bloodstream infection in a patient who has a central line in place. A central line is a tube that is placed in a large vein of the neck, arm or chest and delivers fluids, blood or medications to a patient.
All patients with a central line are at risk for developing CLABSI. Infections may cause patients pain and suffering resulting in a longer hospital stay with more complications and in some cases can be fatal.
GBMC clinicians make it a priority to educate all patients, when possible, about the risks associated with a central line before insertion. As a patient, it’s also important to ask questions of your clinicians such as:
• "Is a central line necessary for my treatment?" • "When can my central line come out?"
It's important to note that the less time a central line is in the patient, the less risk there is for developing an infection.
Proper hand hygiene is the number one way to prevent infection and the spread of disease. At GBMC we routinely monitor our compliance through the use of “secret observers”. Our Hand hygiene rates are the percentage of times staff are secretly observed performing hand hygiene when required:
Upon entry and exit from a patient's room
Prior to patient contact
After removing gloves
Before an invasive procedure
Before and after touching soiled dressing or a wound
The national average for hand hygiene compliance in all the above situations is 42 percent. Clinicians and staff are recommended to use soap and water for 15 seconds or use alcohol-based hand sanitizer. Our goal at GBMC is to reach 100 percent compliance. Patients are encouraged to ask clinicians if they have washed their hands. Although this may be difficult, clinicians have become used to this as a standard question from patients and don’t mind being asked.
A serious safety event is an unanticipated adverse event that is not part of the natural course of the patient’s disease, which results in serious harm to the patient or has the potential to result in serious harm. It is our goal at GBMC to significantly reduce these types of events.
The goal of GBMC is to provide perfect care to our patients; when an SSE does occur, we review our system of care to identify ways to prevent that event from happening in the future.
Using an advanced electronic reporting tool, GBMC staff and clinicians are able to take a close look at every safety event, examine why it happened and provide learning throughout the organization on the best safety practices.
Patients can assist in preventing safety events by being an active part of the healthcare team. Patients should be aware of their medications and treatment. We encourage patients to ask three important questions of their healthcare providers:
• What is my main problem? • What do I need to do? • Why is it important that I do this?
We also strongly encourage patients to carry a current list of medications and to know how and why to take them. Open communication between patients and their care providers is important. If something doesn’t seem quite right, patients should ask their provider. For more information, visit the National Patient Safety Foundation at http://www.npsf.org/for-patients-consumers/patients-and-consumers-key-facts-about-patient-safety/.
Surgical Site Infections as Identified Through NSQIP
The National Surgical Quality improvement Project follows randomly selected, consecutive surgical patients for thirty days following their procedures to give an accurate measure of the development of a surgical site infection or other complications.
Now more than ever, patients are seeking information about the quality of care they’re receiving and what their hospitals are doing about improve. GBMC has always maintained a focus on quality, especially in the area of surgical quality improvement. Because of this commitment, GBMC participates in the American College of Surgeons National Quality Improvement Program (NSQIP.) This is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care.
Only about 10 percent of hospitals participate in this program. GBMC feels that the in-depth knowledge gained from NSQIP makes this an important investment. Patient education is a huge part of this program and GBMC has made a significant commitment of time and resources to ensure patients are receiving proper education on a number of issues such as home care, postoperative instructions and rapid identification of issues that could be or may lead to infection.
Patients should always follow the instructions of their care providers to reduce the risk of such issues as surgical site infections.
A Surgical Site Infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical Site Infections are the second leading cause of healthcare associated infections (HAIs) nationwide.
Anyone undergoing surgery is at risk for a surgical site infection. SSIs can range from minor infections causing redness and irritation at the incision site to the more serious infections that would require implant removal and further surgeries.
GBMC has many new initiatives to help protect patients against surgical site infections. As a part of Project JOINTS, an initiative GBMC is participating in with the Institute for Healthcare Improvement (IHI), patients undergoing elective hip and knee replacement surgery are given special preoperative baths and cleansing wipes to use at home prior to surgery. These wipes reduce the amount of bacteria on the skin, which is the most common cause of surgical site infections. Patients are will also screened for methicillin Resistant (and Sensitive) staphylococcus aureus (MRSA and MSSA) by obtaining nasal swabs before admission to the hospital. If the organisms are found, patients will be treated before surgery.
Patients are encouraged to ask their surgeons what measures are being taken to prevent surgical site infections.
At GBMC, we measure compliance with best practices for several common diseases and care processes. Our dashboard provides an overview of the total score within each measure, known as a composite score. A perfect score is 100 percent.
GBMC's goal is to deliver consistent, quality care following evidence-based practices. These practices have been shown to improve outcomes and reduce the risk of complications. For example when having surgery, we know that when patients receive their antibiotic within one hour of the time of incision, they have reduced risk of surgical infections. We measure how well we follow the best practices and work to provide perfect care.
There are 33 Core Measures for four different care processes.
• Acute Myrocardial Infarction • Community Acquired Pneumonia • Congestive Heart Failure • Surgical Care Improvement Project
It's important for patients to be aware of these measures, particularly those that affect them directly. Patients and families are always encouraged to have a questioning attitude about their healthcare. Asking questions is the best way to understand why certain tests are ordered and treatments are given.
(Note: These measures are a requirement for participation in the Medicare/Medicaid program and results, although about 9 months old, are available on www.hospitalcompare.hhs.gov.)
Any hospice patient (residing in their home, in a facility or in the inpatient centers) under the care of Gilchrist Hospice Care with an incidence or evidence of pain, should be brought to his/her comfort level within 24 hours.
Some patients with end stage diseases that are served by Gilchrist Hospice experience varying levels of pain. The national comfort measure question for individuals receiving hospice care asks: “Was the patient brought to comfort within 48 hours of admission?” A patient’s comfort is Gilchrist Hospice Care’s highest priority and as such, has set its goal for patients to be brought to their comfort level within 24 hours for any incident of pain.
It’s important for patients to get relief as soon as possible so that they’re able to spend as much quality time with their loved ones at the end of life.
Patients and families should stay informed about the types of medication being administered and potential side effects. Some good questions to ask the care providers are:
• What are the effects of this medication? • Are there any pain relief alternatives to medication? • What can be expected within the next 24-48 hours? • Are the side effects temporary or will they last only for the duration that the patient is on the medication?
A patient’s pain level is routinely assessed by talking about the pain they’re experiencing and finding out information such as the level of pain and where the pain is located. Medication adjustments can be made after each assessment.
For patients who are unable to self report, care providers look for non-verbal clues such as grimacing, body rigidity, facial expressions and guarding of certain areas when they move, to help care providers determine if the patient is experiencing pain. Patients are monitored for effectiveness of the medication which can be adjusted as necessary until the patient’s signs and symptoms of pain have been relieved.
The Board Quality Committee
The Board Quality Committee is responsible for oversight of the quality and safety of the care provided to patients of the GBMC Healthcare. The membership includes board members, physicians, nurses, patients and family members. The Committee recommends and oversees achievement of the annual quality and safety goals. In addition, they work with leadership to promote a culture of safety throughout the organization. Reports are provided to the Board of Directors at every meeting. Quality and Patient safety is the first report on the Board agenda which allows ample time for discussion.
Have a question about patient safety at GBMC? Contact Us
The Hon. Vicki Ballou-Watts Mrs. Sandra Berman John B. Chessare, M.D.
Kate Devan, R.N. Cate O’Connor-Devlin, R.N. Timothy Doran, M.D.
Ms. Darlene Fleischmann, E.S.Q. John Flowers, M.D. Paul Foster, M.D.
Neal Friedlander, M.D. Amanda Icenroad, R.N. Mr. Timothy L. Krongard
Ms. Jane Mace Mr. Jerry McCan Ms. Jeannette Mills
Ms. Patricia J. Mitchell Dorothy Needer, R.N. Robert Palermo, M.D.
Mr. Frank Palmer Mr. John Reith Melissa Sparrow, M.D.
Ms. Bonnie Stein, Chair Nicole Stuckey, R.N. Mr. Steven Thomas , E.S.Q.
Ms. Marion Thompson, Vice Chair Harold Tucker, M.D. Brian Watson
John Wogan, M.D. Ms. Carolyn Candiello Jody Porter, D.N.P., R.N.