Patient Experience Overall Hospital Rating — HCAHPS

Patient Experience Overall Hospital Rating — HCAHPS

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 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

Catheter Associated Urinary Tract Infections

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

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.

Hand Hygiene

Hand Hygiene

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.

Reduce Serious Safety Events

Reduce Serious Safety Events

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

Surgical Site Infections as Identified Through NSQIP

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.

Surgical Site Infections — Hips & Knees

Surgical Site Infections — Hips & Knees

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.

Core Measures

Core Measures:

At GBMC, we measure compliance with best practices for several common diseases and care processes. 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. Our dashboard provides GBMC's quarterly score, as well as a comparative score. For some measures, a higher score is better, while for other measures, a lower score is better.

The five displayed Core Measures are as follows:

  • Acute Myocardial Infarction - Median Time to Transfer to Another Facility for Acute Coronary Intervention
    • The earlier acute coronary intervention (e.g., primary angioplasty) is provided to patients with heart attacks, the more effective it is in reducing mortality and morbidity (e.g., diseases or conditions). Therefore, the less time it takes for patients to be transferred to another facility for an acute coronary intervention, the greater the reduction of risk to the patient.
  • Emergency Department Care - Median Time for Pain Management for Long Bone Fracture
    • When pain management is part of an emergency department's treatment regimen, pain management improves for patients with long bone fractures. When these pain management treatment regimens are integrated in to performance measures, pain management for long bone fractures continues to improve.
  • Perinatal Care - Mothers - Elective Cesarean or Vaginal Delivery >=37 weeks and <39 weeks
    • Infants electively delivered between 37 and 39 weeks gestation are at a greater risk for neonatal morbidities (e.g., diseases or conditions). We also know that these elective deliveries are more likely to result in a cesarean delivery, as well as a longer maternal length of stay. Therefore, the lower the rate of elective deliveries between 37 and 39 weeks gestation, the greater the reduction in risk to both the infant and the mother.
  • Perinatal Care - Infants – Exclusive Breast Milk Feeding
    • The World Health Organization (WHO), Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP), and American College of Obstetricians and Gynecologists (ACOG) have consistently promoted exclusive breast milk feeding for the first 6 months of an infant’s life. Evidence has proven that the prenatal and intrapartum (labor and delivery) period is critical for the success of exclusive (or any) breastfeeding. Therefore, the higher the rate of exclusive breast milk feeding, the greater the benefit to the infant.
  • Perinatal Care - Infants -
    Exclusive Breast Milk Feeding
    • The World Health Organization (WHO), Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP), and American College of Obstetricians and Gynecologists (ACOG) have consistently promoted exclusive breast milk feeding for the first 6 months of an infant's life. Evidence has proven that the prenatal and intrapartum (labor and delivery) period is critical for the success of exclusive (or any) breastfeeding. Therefore, the higher the rate of exclusive breast milk feeding, the greater the benefit to the infant.
    Health Care-Associated Bloodstream Infections in Newborns
    • Health care-associated bacteremia is a significant potential problem for infants, especially those with a very low birthweight, who are admitted to Neonatal Intensive Care Units (NICU) and other hospital units. Given the fragility of this particular patient population, a baseline of health care-associated infection is expected, even with good protocols in place. However, preventive measures ranging from hand-washing protocols to multidisciplinary plans involving nutrition, skin care, respiratory, vascular, and diagnostic practices have been shown to substantially reduce infection rates.
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. Results for these measures, although approximately 9 months old, are available on

Hospice Patient Comfort Within 24 Hours

Hospice Patient Comfort Within 24 Hours

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

Committee Members

Mrs. Sandra Berman

Ms. Carolyn Candiello

John B. Chessare, MD

Cate O'Connor-Devlin, RN

Timonthy Doran, MD

Ms. Kaye Flamm

Ms. Darlene Fleischmann, ESQ

John Flowers, MD
Jerry Focas

Paul Foster, MD

Neal Friedlander, MD

Mr. David Hynson

Amanda Icenroad, RN
JoAnn Ioannou, DNP, RN

Ms. Jane Mace

Mr. Jerry McCann

Mrs. Catherine McDonnell

Dorothy Needer, RN
Tom O'Donnell

Robert Palermo, MD

Melissa Sparrow, MD

Mr. Steven Thomas , ESQ

Ms. Marion Thompson, Chair

John Wogan, M.D.


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