Measuring Patient Safety

Our patient safety measures are guided by the Agency for Healthcare Research and Quality through staff studies, the results of which are reported annually.

Culture of Safety

One of our patient safety measures is known as the "culture of safety”—that is, how we as providers and employees perceive the safety of the hospital and our ability to and comfort in reporting safety issues or concerns. Our current patient safety study is underway and the results will be reported later this summer.

Hand Hygiene

Hand washing has been proven to be the best way to prevent the spread of infection. We not only monitor our staff's hand hygiene compliance, but we also encourage our patients to ask caregivers if they have washed their hands when entering a room or before performing a procedure.

And it doesn't stop there. In addition to measuring hand hygiene compliance, we monitor the stocking and readiness for use of isolation caddies and the use of personal protective equipment (PPE) by care providers.

Safety and nursing staff measure compliance by observation during daily rounding; measurements are reported weekly. Currently, our hand hygiene compliance level is 84 percent compared with a state compliance level of 82 percent.

Hospital-Acquired Conditions

A hospital-acquired condition (HAC) is any infection not documented as "present on admission" and is therefore assumed to have been contracted during a patient's stay. We measure HACs in a variety of ways, including:

• Hip/knee surgical-site infections: When such infections are identified, the appropriate staff receives what we call “right-on-time" education. This immediately helps to reduce future infections.
• Readmission rates: Readmissions are "all-cause," meaning based on any condition for which a patient is readmitted, whether or not it is related to the original surgical or other procedure. For example, a patient who had a knee replacement at Beaufort Memorial and after discharge goes to ANY emergency department for ANY reason, such as the flu or pneumonia, is considered to be a Beaufort Memorial readmission. Last year 39 of 593 hip and knee patients were readmitted within 30 days of discharge.