Quality, Safety and Infection Control
Our commitment to our mission, Excellence in Care and Service, is demonstrated in the Quality of Care that we provide. Our team is dedicated to continuously strive to give our patients the absolute best experience by maintaining the highest level of commitment to:
Our Commitment to Quality = Results
- improving the quality of care
- keeping our patients safe
- service excellence and
- promoting more effective and efficient utilization of facilities and service
The Institute of Medicine (IOM) defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
In Crossing the Quality Chasm (2001), the IOM’s Committee on the Quality of Health Care in America identified six aims for improvement, stating that “health care should be safe, effective, patient-centered, timely, efficient, and equitable.”
What quality means to us:
• keeping the patient at the center of what we do
• keeping our patients safe
• providing care that leads to excellent outcomes
• providing care that is evidence-based
• providing compassionate care and service that leads to an exceptional patient experience
• constantly striving for excellence
• continually examining what we do and how we do it, in order to improve the care and services that we provide
Continuous Quality Improvement (CQI) Program
The following Quality Measures are required for those participating in the CMS ASC Quality Reporting Program:
- ASC-1 Patient Burn
- ASC-2 Patient Fall
- ASC-3 Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant
- ASC-4 Hospital Transfer/Admission
- ASC-5 Prophylactic Intravenous (IV) Antibiotic Timing
- ASC-6 Safe Surgery Checklist Use
- ASC-7 ASC Facility Volume Data on Selected ASC Surgical Procedures
- ASC-8 Influenza Vaccination Coverage among Healthcare Personnel
- ASC-9 Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients
- ASC-10 Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps- Avoidance of Inappropriate Use
- ASC-12 Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
The process of continuous quality improvement is critical to meeting the needs of our patients and living the mission of our organization. The Quality Improvement Program is an active program that is integrated throughout the organization. Each area of the organization is involved with improving performance and the quality of the services we provide.
Quality Measures and Performance Measures are indicators that are monitored and analyzed in order to assess quality and performance. Based on these indicators, we are able to identify opportunities for improvement and take action to continuously improve the care and service that we provide. Our CQI program monitors several different types of measures, including the measures defined in the Centers for Medicare and Medicaid Services (CMS) Ambulatory Surgery Centers Quality Reporting Program. CMS selected measures that direct the focus in the ASC setting on improved health care outcomes, quality, safety, efficiency and satisfaction for patients.
Accreditation Association for Ambulatory Healthcare
Mississippi Valley Surgery Center and Mississippi Valley Endoscopy Center are accredited by the Accreditation Association for Ambulatory Health Care (AAAHC). The AAAHC accreditation program adheres to the highest standards and established best practices, including Medicare Conditions for Coverage. The AAAHC accreditation demonstrates our organization’s commitment to our patients and to providing the highest quality of patient care.
Infection Prevention Control and Safety
Our Infection Prevention Control and Safety program is ongoing comprehensive program that includes ongoing observation, investigation, prevention measures to control infections and communicable diseases; while adhering to safe practices for patients, employees, medical staff and allied health professionals. Our program is based on recommendations from nationally recognized organizations and government agencies such as The Occupational Safety and Health Administration (OSHA), Centers for Medicare and Medicaid Services (CMS), Association for Professionals in Infection Control (APIC), Association for the Advancement of Medical Instrumentation (AAMI) and Association of Perioperative Registered Nurses (AORN). Following these guidelines ensures that our patients are provided a safe and sanitary environment of care.
Infection prevention is everyone’s job. Each of us has an important role to play in keeping patients safe and free from infection and harm. Some of these key ways are:
- Hand Hygiene, this is the most important way to prevent the spread of infections to our patients. Hand hygiene is a process measure that is monitored on a monthly basis and reported to our CQI committee monthly.
- Following safe injection practices – One needle, one syringe, only one time.
- As part of a Surgical “Safety Checklist” we make patient identification a priority; the practice of having the patient involved in identifying themselves and using “two patient identifiers” (name and date of birth) is essential in improving the reliability of the patient’s identification process. The use of two identifiers also helps ensure that a correct match is made between the service or treatment and the individual. This process will help eliminate errors and enhance patient safety.
- Monitoring Surgical Site Infections, each surgeon is required to report monthly, surgical site infections and any complications their patients may have developed. This information is thoroughly reviewed and monitored for trends; to measure quality and performance; and identify opportunities for improvement.