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