 At INTEGRIS Canadian Valley Regional Hospital, we believe it is important to be as transparent as possible. We already lead the state by sharing information about the quality and the expected cost of the care we provide. Our mission, “to improve the health of the people and the communities we serve,” can only be achieved fully if we are constantly looking to better ourselves.
In that spirit, I would like to share the results of our review from the Joint Commission. This independent body of experts assesses our performance on more than 250 standards with the focus on improving the quality and safety of care we provide. If a surveyor has a concern about the process of care, an “RFI” (Requirement for Improvement) may be noted.
INTEGRIS Canadian Valley Regional Hospital was reviewed by the Joint Commission during September of 2006. We understand the need for constant improvement and realize that we are not perfect, no matter how hard we try. While we had a successful survey, there are areas where we can and will improve. We have responded to the Joint Commission with an action plan and are in the process of correcting the “RFIs.” It is not our goal to simply meet the standards set forth by the Joint Commission, but to exceed them and continuously set them higher.
INTEGRIS Canadian Valley Regional Hospital is committed to going above and beyond the requirements of the Joint Commission in an effort to offer the best quality of care to our patients and communities. We feel that it is important to be open about our performances because we want to be held to the highest standards, yours. Thank you for taking the time to review our report and we welcome any feedback that you would like to provide.
Thank you,
James D. Moore, FACHE
President
INTEGRIS Canadian Valley Regional Hospital
Effectiveness of Communication Among Caregivers
What did the Joint Commission find?
The surveyor recommended that a process be implemented to measure and assess the time required to report critical lab results to the patient's physician.
Why is it important?
It is important to provide this information to the physician so that timely decisions can be made in the care of patients.
What are we doing about it?
We have reviewed our critical values reporting process with our nursing staff. We have also done staff education and placed more emphasis on consistent documentation of the communication to physicians in a log book.
Where are we now?
The data in the communication log is being monitored to ensure physicians are notified of critical values within a specified timeframe of receipt from the lab. A lab report that has lab to nursing communication time is compared to documentation in the nursing to physician communication log.
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Medical Staff Oversees the Quality of Patient Care
What did the Joint Commission find?
The surveyor recommended that a process be developed to monitor the quality of medical histories and physical examinations.
Why is it important?
Medical histories and physicals are important because they provide the patient's current and past health status. The information collected provides a foundation for all future medical treatments.
What are we doing about it?
After reviewing current policies, we developed and implemented a policy that our Medical Quality Committee reviews at least 10 random history and physical examination reports a month. A checklist was developed to be used by the committee to assess whether the reports contain all the necessary information.
Where are we now?
We are monitoring the history and physical examination reports on a monthly basis. Those physicians who have submitted incomplete reports are required to complete an addendum to their existing reports.
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Process for Granting Clinical Privileges
What did the Joint Commission find?
The surveyor recommended that a process be developed to ensure that Medical Staff appointments not exceed the two year appointment period as defined by the hospital's Medical Staff Bylaws.
Why is it important?
It is important to regularly verify the license, clinical performance and malpractice activity of medical staff members. We want to ensure that patients receive the best possible care from the most competent medical staff members.
What are we doing about it?
We have reviewed our internal processes to identify barriers to timely renewal of medical staff privileges. We implemented a new process to send medical staff reappointment applications three months prior to appointment expiration to ensure there is sufficient time for medical staff members to complete and return the application.
Where are we now?
We are monitoring our internal process to ensure medical staff members do not exceed the two year appointment period.
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Management of High-Risk/High-Alert Medications
What did the Joint Commission find?
The surveyor recommended the hospital develop a list of high-risk/high-alert medications.
Why is it important?
This is important because there are medications, if administered incorrectly, can immediately cause injury or death.
What are we doing about it?
We have developed a list of high-risk/high-alert medications and reviewed our internal process for administering these medications. The nursing staff has been educated in the administration of these medications so that special precautions are taken to ensure proper patient monitoring after administration.
Where are we now?
We are monitoring our internal process for medication errors and patient medication reactions. We will continue to identify barriers to safe medication administration.
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Data Analysis to Improve Performance and Patient Safety
What did the Joint Commission find?
The surveyor recommended more consistent use of data to identify opportunities for changing processes and the use of data to monitor the performance of the changes.
Why is it important?
This is important because internal processes have to always be monitored and adjusted to ensure safe and efficient delivery of patient care.
What are we doing about it?
We have reviewed our data reporting and follow-up processes with each department manager to ensure common understanding. The department managers have been educated in the importance of data collection and appropriate follow-up once changes are implemented.
Where are we now?
We are monitoring our data to ensure necessary changes are made to improve patient care and safety.
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Proactive Program to Identify and Reduce Safety Risk
What did the Joint Commission find?
The surveyor recommended that at least one proactive risk assessment be done every year.
Why is it important?
These risk assessments are important because the hospital can identify problems with internal processes prior to an incident that causes patient injury or death.
What are we doing about it?
Proactive risk assessment topics have been identified by hospital clinical staff. The hospital has completed one risk assessment and additional assessments will be completed by the end of the year.
Where are we now?
The failure prone processes identified in the risk assessment have been modified to decrease the risk of patient harm. The processes will continue to be monitored to identify barriers and implement necessary modifications.
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Data to Improve Staffing Effectiveness
What did the Joint Commission find?
The surveyor recommended using two inpatient units to collect data about the effect of staffing patterns on patient care and safety.
Why is it important?
This is important because inappropriate staffing patterns can lead to undesirable patient outcomes and experiences.
What are we doing about it?
We identified two inpatient units on which to collect data. We are monitoring the data to determine how staffing patterns affect patient restraint usage, patient falls, medication errors and patient satisfaction.
Where are we now?
We are currently monitoring the data to identify undesirable trends.
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[Visit the Joint Commission Web site for more information.]
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