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Quality News
Click on the links below to view recent Oregon quality news. Click here to view a list of all Oregon quality news articles.
Points of Interest
 Meeting State Reporting Requirements Race & Ethnicity Data - powerpoint
Reducing Disparities in Health Care: A Guide to Data Collection - Powerpoint
Patient satisfaction data is now available for Oregon hospitals. Click here to view the results, and then click on the "Patient Satisfaction" button.
Color-Coded Wristband Tools
Recent Patient Safety Bulletins
OAHHS Quality Strategy Map
ARCHIVED: Quality Advisories
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News from the Joint Commission
Updated Sentinel Event Statistics
As of September 30, 2007, The Joint Commission’s sentinel event statistics have been updated and are now available on the Joint Commission website. The 10 most frequently reported sentinel events are:
Wrong-site surgery - 615
Suicide - 574
Operative/post-operative complication - 557
Medication error - 438
Delay in treatment - 354
Patient fall - 271
Patient death or injury in restraints - 173
Assault, rape or homicide - 171
Perinatal death/loss of function - 141
Unintended retention of foreign body - 130
Since the sentinel event database was implemented in January 1995, the Joint Commission has received 4,693 reports of sentinel events. A total of 4,820 patients were affected by these events, with 3,394, or 70 percent, resulting in patient death.
This information, along with other sentinel event statistics and detailed reports, can be accessed by going to the Joint Commission website at: http://www.jointcommission.org/SentinelEvents/Statistics/
Joint Commission Announces 2009 Patient Safety Goals
OAHHS Quality Advisory: 2009 NPSGs Announced
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Oregon 5 Million Lives Network
OAHHS is a node for the national 5 Million Lives Campaign and a partner in the Oregon 5 Million Lives network along with Acumentra Health, the Oregon Patient Safety Commission, the OMA, the ONA and Care Oregon. Click here for information and resources on the national 5 Million Lives Campaign and Oregon activities.
To enroll your hospital in the 5 Million Lives Campaign, go to www.ihi.org or click here.
May 8, 2008 IHI Spring Conference
Over 100 attended the IHI Spring Conference at the OMA sponsored by the Oregon 5 Million Lives Network.
It was a valuable day of networking and sharing of ideas and issues for Oregon hospitals. The presentations are available for you as follows:
Our Board is on Board
Ventilator Associated Pneumonia Prevention
AMI Transformation
Prevention of Central Line Assoc. Infection
If you are prompted for a password when you hit one of the links, simply hit cancel.
Engaging Physicians in Your Quality Agenda
A white paper written by the Institute for Healthcare Improvement (IHI) focuses on physician engagement and involvement in a hospital’s quality agenda. There are many competing factors to this issue, and this white paper takes these issues on. An excerpt from the white paper is cited below and demonstrates the depth of understanding in this issue.
“A critical fact about hospitals is that very little happens in the health care system without a physician’s order. By virtue of physicians’ plenary legal authority, which is broader than that of any other actor on the health care scene, almost all actions in health care are derivative of their decisions and recommendations. Therefore, any changes in the way care is designed and delivered require physician acceptance, either as individuals or as a professional body (e.g., the Medical Staff Executive Committee).”
Given the deep-seated nature of these realities, and the importance of physician engagement to achieving quality results, it is surprising that so few hospitals have actually articulated a plan to improve the engagement of their physicians. The primary purpose of this white paper is to provide a framework, a sort of scaffold, on which hospital leaders might build a written plan for physician engagement in quality and safety.
Click here to access the white paper, "Engaging Physicians in a Shared Quality Agenda."
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Hospital Quality Indicators
To view quality indicators
for all reporting Oregon hospitals, click on the button below. The indicators currently available are reported to the Centers for Medicare and Medicaid Services, and include heart attack, heart failure, pneumonia, surgical infection prevention and patient satisfaction.
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Oregon Quality Community
The Oregon Quality Community (OQC) is a collaborative effort between OAHHS and the Oregon Medical Association (OMA) to improve the quality of health care in Oregon. Specific objectives will be determined by a Steering Committee. Current members include:
Suzi Bean, RN, Mountain View Hospital
Sarah Slaughter, MD, Providence Portland Medical Ctr.
Manny Berman, Tuality Healthcare
Steve DeLashmutt, MD, Baker City
Patricia Martinez, MD, Asante Health System
Robert Dannenhoffer, Mercy Medical Center
Kevin Winthrop, MD, OHSU
The Steering Committee Staff includes Gwen Dayton, OAHHS, Diane Waldo, OAHHS and Paul Frisch, OMA.
Hand Hygiene Pilot Project Update
Phase I of the hand hygiene project was completed in April 2008; nine hospitals completed a pilot project to improve the consistency of hand hygiene compliance within their facility. The project involved both patients and care givers. Patients were encouraged to ask their care providers if they washed their hands. The amount of soap/gel/foam used on patient care units was collected monthly as well as the number of patient days to calculate a compliance rate based on a standard for the type of unit. Reports were generated monthly to provide timely feedback to hospital administration and staff.
The Oregon hospitals that participated in Phase I of the OAHHS Hand Hygiene Project included:
Sacred Heart Medical Center
Adventist Medical Center
Tillamook Hospital
Mid Columbia Medical Center
Samaritan Pacific Community Hospital
Grande Ronde Hospital
Columbia Memorial Hospital
Mountain View Hospital
Providence St Vincent Medical Center
For questions about this quality project, please call Diane Waldo at 503-479-6016 or email at diane.waldo@oahhs.org
All nine hospitals are continuing to participate in the hand hygiene project to further improve their efforts in hand hygiene compliance.
Phase II of the hand hygiene project was offered in an informational webinar held on May 6, 2008 followed by an implementation meeting on June 6, 2008. Twelve additional hospitals had representatives present to participate. All twelve hospitals began baseline data collection during July and August 2008.
 Click here for "Hand Hygiene Project: Moving Forward" Presentation from May 6, 2008.
Click here to download the Power Point presentation by Dr. Woody English from the June 14, 2007 hand hygiene meeting.
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Oregon Quality Ideas in Action
Oregon Rural Health Quality Network members form a Quality Council
The Oregon Rural Health Quality Network (ORHQN) formed in 2005 to improve the quality and safety of health care in rural Oregon with a vision that its Members shall lead the nation in establishing rural quality standards and benchmarking to improve and promote a healthy community. Members of the ORHQN include 24 of the 25 critical access hospitals in Oregon.
Earlier this year, the ORHQN Board requested the ORHQN member quality leaders to develop quality and performance improvement initiatives to meet its objective of becoming a “national model of excellence.” Four strategic initiatives were created and include the following:
Service Excellence and Patient Satisfaction: Focus is to publicly report HCAHPS information (not required for critical access hospitals), RPM satisfaction surveys, measuring and improving customer service and implementing service excellence. Project leader: Elaine Young at Columbia Memorial Hospital. Contact Elaine at 503-730.2346 or email at Elaine_young@columbiamemorial.org
Click here to view additional Oregon quality ideas in action!
Do you have a case example to share? Please contact Diane Waldo.
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