QUALITY REPORT 2008

January 2009

Dear Friends:

From Munroe’s founding in 1898, quality of patient care has been at the forefront of our mission. This tradition continues and is accelerating, making Munroe Regional Medical Center the acknowledged leader in providing advanced comprehensive care to Marion County and beyond.

Our excellence is reflected in how the community perceives us, culminating in our repeated Consumer’s Choice awards; in how our community physicians choose to use our facilities, with the majority of the market share in services provided; and in how external agencies rate us, with numerous awards and recognitions listed on the following pages.

Munroe Regional continues to make a profound impact on the quality of life in our community. We are the sole provider of obstetrical services in Marion County, with nearly 3,000 births annually. We are also the sole provider of hospital pediatrics care.

Cardiovascular disease is the primary burden of illness in Marion County, and Munroe Regional has responded to this need by developing a nationally recognized heart program over the last 20 years. From inception in 1988, our open-heart surgery program has performed over 11,000 procedures with outcomes that rival the best in the nation. Our cardiac catheterization program is recognized as the # 1 Cath Program in Florida for Coronary Interventions for second straight year and top 4% in the nation by HealthGrades.

Support for the care of the most ill patients is vital to the health of any community and our intensive care units are recognized as among the best in the nation. The Association of Critical Care Nurses has awarded Munroe Regional’s ICU with their Beacon Award as a best in class program. Only five organizations in the country, and none in Florida, have equaled this achievement. Beginning in 2009, our intensive care units will be enhanced by maintaining a critical care trained physician in the units on a continuous, 24 hours a day basis. Few hospitals can provide this kind of service.

Quality is not an outcome, but is a journey. On the following pages are many of the stories that tell where Munroe Regional has pursued excellence and where our journey is taking us, and our community, in leading healthcare for Marion County.

Sincerely,

Lon H. McPherson, MD                                                    Stephen A. Purves, FACHE
SVP of Medical Affairs & Chief Quality Officer                 President & CEO
Munroe Regional Medical Center                                    Munroe Regional Medical Center


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TABLE OF CONTENTS

Introduction
  Welcome   1
  Mission, Vision, Core Values   2
  Accolades and Awards   3
  Munroe’s History   4
VHA Southeast Quality Score
  Hospital Quality Score   7
Patient Safety
  Patient Safety Program   9
  Serious Adverse Events (Never Events)   11
  Adverse Drug Events   12
  National Patient Safety Goals   14
  Hand-off Communication   16
  Hospital Access   18
  Rapid Response Team   20
  Fall Prevention   21
Heart Care
  Heart Attack* (Acute Myocardial Infarction - AMI   25
  Heart Failure*   27
  Interventional Cardiology   29
  Cardiac Surgery – CABG   31
Surgical Care
  SCIP*   33
  Hip and Knee Replacement   36
Critical Care
  Critical Care Medicine   39
Medicine
  High Alert Medications   42
  Pneumonia*   44
  Venous Thromboembolic Prevention   46
  Heart Failure Treatment Center   47
  Associate Flu Vaccinations   48
Diabetes Healthways at Munroe Regional
  Diabetes   50
  Wound Care   51
Bariatric
  Bariatric Program   53
Infection Control
  Infection Control Program   55
  MRSA   56
  c-Difficile   58
  Central Line Blood Stream Infections   60
  Ventilator Associated Pneumonia   62
Women and Children’s Health
  Pediatric Asthma   64
  Improving Perinatal Care   65
Stroke Center
  Stroke Care   68
Patient Loyalty
  Patient Loyalty - Inpatient   70
Performance Improvement
  2008 Breakthrough Objectives   72
       
*Core Measures – Heart Failure, AMI, Pneumonia and SCIP
Patients describe their experience with Munroe's Accredited Chest Pain Center:
  • D.J. Johnson
    D.J. Johnson describes his experience with Munroe's Accredited Chest Pain Center.

  • Steve Kenworthy
    Steve Kenworthy describes his experience with Munroe's Accredited Chest Pain Center.
Heart conditions and diseases