Quality and Safety

Our standards of quality are founded on six principles.

Each day, we work hard to provide care that is:

Safe: We ensure you are physically safe while in our care.
Timely: We treat you without unnecessary delay.
Effective: We treat you with evidence-based medicine.
Efficient: We treat you without waste or overuse.
Patient-centered: We work to earn your trust, include you in all decision-making and help you find hope.
Equitable: We provide care that doesn’t vary in quality due to gender, ethnicity, geographical location or socioeconomic status.

Sometimes complications happen. To offer constant transparency, the Department of Health shares reports that relate the rate of occurrence of the following measures:

• Central line-associated bloodstream (CLAB) infections
• Mediastinitis, a surgical site infection following coronary artery bypass graft (CABG)

Available on their website, each biannual publication provides the state of these measures for the previous four quarters. Data is aggregated by the CDC National Healthcare Safety Network (NHSN).

Here, we believe that knowledge is power. That’s why we give you access to our success rates through quality reports that measure patient satisfaction and our performance on a national scale.

These reports, updated quarterly, relate our composite scores by showing the compliance of our patient care with best practices for common conditions, including heart attack (acute myocardial infarction, or AMI), heart failure, pneumonia and surgical infection prevention.

Our performance is evaluated against standardized measures, so we can maintain a standard of excellence and help patients like you receive the best quality care.

Because your health is our priority, we’re constantly striving to deliver the very best health services and outcomes. That’s why we seek accreditation from national organizations like The Joint Commission, which creates national patient safety goals to help health systems continually improve patient care, safety and long-term health.

As a part of the accreditation process, we must meet these goals, ensure a safe health care environment and make improvements where needed. And to do that, we continually adjust our systems and procedures to guarantee we meet these standards of care.

We also recognize that sometimes it may be necessary to do your own research. Status reports relating how our facilities are performing and comparing to other health care organizations are available on QualityCheck.org.

"The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." (Institute of Medicine)

In response to these challenges, the Institute of Medicine has established six aims for improvement. Health care should be:

1. Safe: avoiding injuries to patients from the care that is intended to help them.
2. Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse).
3. Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patients' values guide all clinical decisions.
4. Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
5. Efficient: avoiding waste, including waste of equipment, supplies, ideas and energy.
6. Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status.

(Excerpt: Crossing The Quality Chasm, A New Health System for the 21st Century, Institute of Medicine, 2001, National Academy of Sciences.)

Patient safety has been defined as a patient's freedom from accidental injury when interacting in any way with the health care system.

Hospital-acquired infections (HAIs), are infections that patients can get after having medical or surgical treatments. These infections can happen when needles and tubes are inserted through a person's skin. The insertion of needles and devices provides a pathway for bacteria and other organisms to enter the bloodstream and lungs.

Patients in the intensive care unit (ICU) have the highest risk of HAIs because of the number of procedures they undergo and the seriousness of their health problems. HAIs can aggravate a patient's illness and lengthen their stay in the hospital. They also can be passed on to other individuals.

These infections may include:

• Central line-associated bloodstream (CLAB) infections
• Mediastinitis, a surgical site infection following coronary artery bypass graft (CABG)

The Department of Health will publish on their website infection rates for CLAB infections in intensive care units. The reports will be updated every six months with the most recent four quarters of data.

Additionally, the department will report only aggregate statewide CABG surgical infection rates. Data will be reported through the CDC National Healthcare Safety Network (NHSN).

2018

• First Place - Josh Nahum Award for Infection Prevention: “A Systematic Approach to Reducing Catheter Associated Urinary Tract Infections in a Community Based Hospital”
• Second Place Hospital /Health Systems: “Reducing Ionizing Radiation Exposure for Patients – A Multi-Hospital Systems’ Approach”
• Third Place - Quality and Patient Safety Award for Hospitals with 100-299 Beds “Extubation Celebration: Less is better!”

2017

• Third Place Josh Nahum Award for Infection Prevention: “Know Sepsis: Identifying the Signs and Symptoms Early to Reduce Mortality and Improve Patient Care”

2016

• First Place Quality and Patient Safety Award for Hospitals with 100-299 Beds “Improving IV Pump Safety and Effectiveness of Alarms!”

The Circle of Excellence is for hospitals that have demonstrated a sustained commitment to quality and patient safety, as evidenced by earning three or more patient safety awards from the Georgia Hospital Association's Partnership for Healthcare and Accountability within the previous five years and being a current award winner in the year of the Circle of Excellence Award.

The “Door-to-Needle Time” award is given to hospitals that have entered a minimum of five patients in 2015 with an average door-to-needle time of less than 45 minutes. The award is also offered to hospitals that have shown a 20% decrease in door-to-needle time compared to the previous year.

AdventHealth Redmond has treated a minimum of 85% compliance to the core standard levels of care, as outlined by the American Heart Association/American College of Cardiology secondary prevention guidelines for Heart Failure Patients.

Target: Stroke is a national quality improvement campaign of the American Heart Association/American Stroke Association designed to improve outcomes for ischemic stroke patients by helping hospitals achieve door-to-needle (DTN) times of 60 minutes or less.

We are honored to be accredited by The Joint Commission, which accredits and certifies more than 15,000 health care organizations and programs in the United States.

Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards. Accreditation is awarded to a health care organization that is in compliance with all standards at the time of the on-site survey or has successfully addressed requirements for improvement within 90 days following the survey.

We hold seven certificates from the Joint Commission for outstanding care:

• Acute myocardial infarction (AMI)
• Vascular surgery, abdominal aortic aneurysm, and carotid stenosis
• Advanced heart failure
• Advanced primary stroke center
• Joint replacement - hip
• Joint replacement – knee
• Spine

The American College of Radiology (ACR) is a professional medical organization dedicated to making imaging safe, effective and accessible to those who need it. Accreditation means AdventHealth Redmond’s radiologists and technologists meet ACR standards of image quality, personnel qualifications, equipment requirements, quality assurance and quality control.

AdventHealth Redmond has multiple ACR accreditations:

• Breast Center of Excellence
• 2016 Designated Lung Cancer Screening Center
• 2012 to present - Accreditation of Magnetic Resonance Imaging Services for Head, Spine, Body, MSK, and MRA
• 2012 to present - Accreditation for Mammography's Three Units
• 2010 to present - Accreditation of Nuclear Medicine Services
• 2010 to present - Accreditation for Breast Ultrasound and Ultrasound-Guided Biopsy

The Society of Chest Pain Centers (SCPC) has an organizational mission dedicated to the improvement of the clinical processes for the early assessment, diagnosis and treatment of acute coronary syndromes (ACS) and heart failure (HF) within facilities serving our communities.

Redmond is leading the way in improving lung cancer outcomes by providing lung screenings for those at-risk as part of their continuum of multidisciplinary care for lung cancer.

Commission on Cancer accreditation is nationally recognized by organizations, including the National Cancer Institute, Centers for Medicare & Medicaid Services, National Quality Forum, American Cancer Society, and The Joint Commission, as having established data-driven performance measures for the provision of quality cancer care.

You can't improve what you don't measure. That is why we're committed to measuring and publicly reporting our performance. In these quality reports, we show our patient satisfaction scores and performance on nationally recognized quality indicators and practices. These measures will help you assess our clinical quality on specific procedures and conditions compared to established national standards and other hospitals.

Quality reports will be updated quarterly.

Heart attack, heart failure and pneumonia are common reasons why patients go to the hospital and affect hundreds of thousands of patients each year.

We present composite scores for each of the quality report measures. Each graph shows our percent compliance with every process of patient care being measured. For example, a score of 95% means we were compliant with patient care best practices 95% of the time.

Also known as national quality improvement goals, quality measures are important because:

• Achievement of these goals is evaluated against standardized performance measures that hospitals are expected to follow for improving patient care and outcomes.
• Health care providers recognize these as desirable goals for treating patients with the identified conditions.
• Patients who receive care based on certain desirable practices are more likely to improve or avoid other medical problems.