PA hospital implements simple solutions to become top performer
St. Luke’s Miners Memorial Hospital, a 45-bed acute care hospital in Coaldale, PA, serves Schuylkill, Carbon and lower Luzerne counties. Founded in 1910, it became a member of St. Luke’s Hospital & Health Network in 2000. The hospital healthcare specialties include home health, a skilled nursing facility, radiology, physical therapy, oncology, cardiopulmonary care, wound therapy, a sleep disorders center and outpatient services, along with other services including health centers. www.slhn.org
Situation:
For participants in the first year of QUEST the top-level performance challenge included:
- Delivering all recommended evidence-based care measures – often called “perfect care” – at least 84 percent of the time.
- Achieving a mortality rate 18 percent less than expected (O/E = 0.82)
- Safely reducing the cost of care below the midpoint among participating hospitals In the first year of QUEST, St. Luke’s Miners Memorial was one of the hospitals that did not reach top performance in any of the three measures.
Solution:
The hospital team emphasized evidence-based care measures and set about improving the care it provides its patients with simple solutions:
- Concurrent review process was instituted.
- Clinical Quality Data Specialist (a nurse) began making rounds daily on all core measure patients.
- Manager of Quality Resources began meeting weekly with senior administrative team to present compliance data.
- Senior leadership team and Manager of Quality Resources put in place a process to addresses issues directly with physicians, managers and nurses.
Results:
St. Luke’s Miners Memorial Hospital is no longer on the list of hospitals still striving to achieve top-level performance. Process improvement resulted in the evidence-based care measurers improving from the low 80s percent-wise to 91 percent.
"A review of the outcomes demonstrates the positive impact that teamwork and collaboration can have on increasing the use of standardized care processes to better care for our patients. Our advice to other institutions desiring to achieve these results is to appropriate resources for this purpose. We suggest making it someone’s primary responsibility to oversee quality improvement efforts. Our staff is proud and they take the initiative to report success and also ask for clarification or assistance as needed. They are motivated, competitive, empowered and very proud of all they have accomplished. We believe that the processes we have implemented as a result of our QUEST participation can be utilized by other organizations our size to achieve and sustain improvement."
Gail M. Marek
Manager, Quality Resources & Risk Management
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