West Valley Medical Center - November 01, 2018

Renee DeHaas
Director of Patient Safety

Joint Commission Intra Cycle Monitoring Survey

Our 2018 Joint Commission Intra Cycle Monitoring survey commenced on October 15th with a clinical surveyor and engineer present for two days. This survey was intended as a supportive and educational process while we work towards our Triennial Joint Commission Survey due by October 25th of 2019. We were provided with clarification regarding the new Joint Commission SAFER Matrix used for scoring compliance deficiencies as of January, 2017. Also provided was news that unscheduled accreditation surveys are now expected to be earlier than ever; in some cases, up to 6 months in advance. The engagement demonstrated by our clinical, medical and ancillary staff was impressive to both of our surveyors, so we thank you for your participation. Below are five areas of focus for our medical staff, please review and reach out to the Quality department if you have any questions or need clarification.

  1. Range Orders – Nursing can no longer administer medications under a range order. Orders must be specific and define the dosing of medication specific to a patient condition or assessment.
  2. Therapeutic Duplication – Pharmaceutical therapies should not be duplicated.
  3. Documentation – Written documentation should be legible. Signatures need to be dated and timed appropriately.
  4. Moderate & Procedural Sedation – Required pre-sedation and post-sedation documentation must be completed. This includes Mallampati and ASA classifications pre-sedation, as well as appropriate discharge information for those sedation patients who are discharged the same day.
  5. Sterile Attire and PPE – The appropriate attire for OR and sterile procedural areas needs to be worn when indicated. This includes proper hair, beard and shoe covers. Surgical Services will be working with Infection Prevention to further clarify in policy.

Infection Prevention

Safe patient care begins with CLEAN HANDS. The policy at West Valley Medical Center is to clean your hands Before and After patient care. The first protects our patients directly, the second protects you, other staff and the environment. This also applies to wearing GLOVES. Hands need to be cleaned prior to grabbing the gloves out of the box – or else you have just contaminated the outside of these gloves with your unclean hands before touching the patient. Hands need to be cleaned after removing the gloves – no gloves are guaranteed and most likely will contaminate your hands a little. As a reminder, if you are cleaning your hands with soap and water, the scrub of all surfaces of your hands needs to be for 15 seconds after applying the soap. The effect of our non-antimicrobial soap is only from the physical action of removing the pathogens. Recent TJC citations have included staff not washing for the required length of time!

Janet Brooks, Infection Preventionist
(208) 455-4034

Renee DeHaas, Director of Patient Safety
(208) 455-6505

Healthgrades Quality Recognitions 2019

Recognition

Healthgrades Gallbladder Surgery Five-Star Recipient 2019

Healthgrades Total Knee Replacement Five-Star Recipient 2019

Healthgrades Treatment of Gastrointestinal Bleed Five-Star Recipient 2019

Healthgrades Treatment of Heart Attack Five-Star Recipient 2019

Healthgrades Treatment of Respiratory Failure Five-Star Recipient 2019

Healthgrades Treatment of Sepsis Five-Star Recipient 2019

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West Valley Medical Center is honored to be the recipient of its fifth consecutive Healthgrades five-star designation for total knee replacement procedures (2015 – 2019). Healthgrades, a leading online health care resource, announced its 2019 annual awards and ratings October 23.

West Valley’s continued success in the area of orthopedics can be attributed in part to a simultaneous focus on both patient safety and individualized care. The hospital offers patients a Rapid Recovery procedure for knee replacements, which preserves more of the existing bone and results in less damage to the quadriceps muscle. This technique — combined with West Valley’s pre-surgery education classes, dedicated 11-bed orthopedic recovery unit, and ortho-spine service line coordinator — allows patients a faster and less painful return to their active lifestyles.

“We are very proud to once again earn this designation from this nationally recognized group; it exemplifies our commitment and our passion for providing high-quality health care to our growing community,” said Betsy Hunsicker, chief executive officer for West Valley Medical Center. “We thank our physicians and staff for fostering a safe and healing environment for our patients.”

In addition to the fifth consecutive five-star designation for total knee replacement procedures, West Valley is proud to announce the following ratings from Healthgrades:

  • Fourth consecutive Five-Star designation for treatment of sepsis (2016-19)
  • Third consecutive Five-Star designation for treatment of respiratory failure (2017-19)
  • Second consecutive Five-Star designation for treatment of gastrointestinal bleed (2018-19)
  • Second consecutive Five-Star designation for gallbladder removal surgery (2018-19)
  • Five-Star designation for treatment of heart attack in 2019

West Valley is the recipient of the Patient Safety Excellence Award from Healthgrades for two years on a row (2017 – 2018), placing the hospital in the top 10 percent of health care facilities for safety nationwide. This award is announced each spring.

Healthgrades is an online resource that helps consumers search, compare and connect with physicians and hospitals. For its annual “Report to the Nation,” the organization evaluated about 4,500 hospitals nationwide for 34 of the most common inpatient procedures and conditions. The complete Healthgrades 2019 Report to the Nation with detailed cohort-specific outcomes data, hospital-specific quality achievements and detailed study methodology can be found at www.healthgrades.com/quality.

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