Medical Staff Performance Improvement - Mercy Medical Center

Medical Staff Performance Improvement

Posted on: March 13, 2018

Mercy Medical Center physicians are engaged in the 2018 quality initiatives improving hand hygiene compliance and decreasing surgical site infections. Hand hygiene is important for every person and every patient encounter to reduce the spread of infection, especially C-diff. One area of physician concern was the lack of accessible sinks and accessibility of hand sanitizer. 

  • Mercy Plant Engineering will begin installing more hand sanitizer stations to be located outside each patient room beginning next week.
  • Sound physicians can be seen wearing buttons to foam in, foam out as a reminder to health care providers and patients.
  • ICU staff wear buttons encouraging patients to participate and, “Ask me if I have washed my hands?” 

Surgical site infections add treatment, increase length of stay and cause readmissions. This quality metric is a public reported metric and affects hospital payment. A surgical site quality improvement committee will be chaired by Steven Ochs, M.D., and a meeting is scheduled for March 27. Committee goals include standardization of practices and protocols to reduce the chance of an infection occurring.

Sepsis care, using the sepsis bundle, continues to be a quality initiative and once again, Mercy has achieved a decrease in sepsis mortality for 3Q17 (most recent data from OHA). OHA statewide goal is 14.9%, state is 18%, and Mercy is at 10.7% for 3Q17. The sepsis committee recommends attention to the 6-hour assessment as an opportunity for improvement.

Theodore Spangler, M.D., presented a review of radiology cases prepared by Elizabeth Butterworth, M.D., of incidental findings. The study clearly supports an opportunity to improve communication, documentation, and patient follow up. A committee will be convened to look at all opportunities and develop action plans. One action physicians can do immediately is use the problem list to identify findings, include these findings in a discharge summary, communicate to each other if handing off care, communicate these findings to the patient and document the communication.


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