Quality and Prevention Update

Joint Commission and OAS Patient Survey Update ‰лв Jennifer Wagenaar, CNO

We are in the midst of preparation for our next survey. The Joint Commission, the organization that accredits West Valley Medical Center, requires an on-site, unannounced, triennial survey. We expect the onsite visit to last 3-4 days with a physician, nurse and environment/facilities surveyor sometime between now and the end of October. Education to help prepare our physicians was provided at the July all medical staff meeting and the flyer can be found here. Areas of focus for other hospitals this year include timely and complete documentation, appropriate use of and orders for restraints, physician led time-outs, appropriate training and privileging for sedation. Please remember to be welcoming to our guests, answer their questions (but don‰лЊt offer more than they ask) and wear your West Valley name badge.

Standardized ambulatory surgery patient experience surveying has begun at West Valley Medical Center! The Outpatient and Ambulatory Surgery Patient Experience of Care Survey (OAS CAHPS) will collect information about patients‰лЊ experiences of care in hospital outpatient surgery departments (HOPDs) and ambulatory surgery centers (ASCs). We launched the voluntary round of data collection July 1, replacing our current questionnaire. We should have some preliminary data from the new tool in August.

It is likely that in the future CMS will require facilities to conduct the survey as part of the Outpatient Quality Reporting Program or the Ambulatory Surgical Center Quality Reporting Program. We are doing our best to prepare by getting started early. The OAS CAHPS survey contains 37 questions about the check-in process, facility environment, patient‰лЊs experience communicating with administrative staff (receptionists) and clinical providers (doctors and nurses), attention to comfort, pain control, provision of pre- and post- surgery care information, overall experience and patient characteristics. See a complete listing of the new questions.

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Hand Hygiene Compliance Update ‰лв Janet Brooks, RN, Infection Prevention

Infection prevention is a top priority at West Valley and as you know we regularly audit hand hygiene among all providers, hospital staff, students, and volunteers. This data is regularly reported to the Infection Prevention committee, Medical Executive committee, and the Board of Directors. The table below displays licensed independent practitioners‰лЊ compliance with hand hygiene in 2016. The compliance rate listed is calculated by number of occurrences of proper hand hygiene per opportunities for hand hygiene, both before touching and caring for a patient and after touching and caring for a patient. Auditors watch and monitor almost all departments of the hospital to gather this data. The goal for our facility is to be above 90% compliance across the facility. Thank you for your continued diligence in practicing proper hand hygiene and other infection prevention processes.

2016	January	February	March	April	May	June
MD - Before patient care	63%	82%	90%	92%	85%	87%
MD - After patient care	67%	82%	77%	84%	96%	83%
Monthly total compliance	65%	82%	84%	88%	90%	85%

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Sepsis Intervention Update ‰лв Dr. Mike Baumann, division CMO, and Pam Bennett, VP of Quality and Clinic Operations

In September 2014, Dr. Mike Baumann, our division chief medical officer, and Pam Bennett, division vice president of quality and clinical operations, developed a new model to advance the quality and safety of patient care at HCA Mountain Division hospitals.

The model features an interprofessional team of clinical experts, including individuals from quality, clinical documentation, information technology, performance improvement and pharmacy departments.

Led by Dr. Baumann and Pam, this experienced team began collaborating, consolidating their knowledge and harnessing their expertise. Together, they launched an orchestrated approach toward achieving quality improvement goals in 2015 and beyond.

Physician Fact Sheet

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Medical Staff Education Update ‰лв Richard Augustus, CMO

As discussed at our July 26 Medical Staff Business Meeting, two important education documents are now available for your review:

2016 Medical Staff Education Packet

Alert: Compliance Issues with Physicians Sharing Their User ID and Password

Please review both these documents and contact Richard Augustus, CMO, or Karen Bowers, medical staff coordinator, if you have questions or want more information.