The Center for Quality and Safety

In Pursuit of Clinical Excellence

At The Medical Center, quality of care serves as the foundation for everything we do. Our physicians and nurses base their practice on the best scientific evidence, combined with skill and experience. They follow more than 200 protocols and checklists which promote best practice for patients with pneumonia, congestive heart failure, heart attacks, and surgical care.

We benchmark our performance against national organizations such as the National Quality Forum (NQF) and Agency for Healthcare Research and Quality (AHRQ), whose validated employee/staff survey is used to identify opportunities for improvement. The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) are also key standard bearers.

Core Measures

In 2009, The Medical Center achieved Gold Bar status from the Foundation for Healthy Communities for performance in:

• Community Acquired Pneumonia (CAP)
• Congestive Heart Failure (CHF) and,
• Surgical Care Improvement Project (SCIP).
  

To learn more about how Southern New Hampshire Medical Center compares with other New Hampshire hospitals, click here► or for a comparison of specific core measures, follow the links below.

• Acute Myocardial Infarction (Heart Attack) – SNHMC achieved 100% on all indicators during the first quarter 2010.
• Congestive Heart Failure – SNHMC achieved the highest performance in the state and ranked in the top 10th percentile nationally during first quarter 2010.
• Community Acquired Pneumonia – SNHMC has earned Gold Bar Status from Foundation for Healthy Communities for each of the 12 statewide comparative reports and achieved 100% in 2 of 7 measures for first quarter 2010.
• Surgical Care Improvement Project – SNHMC achieved Gold Bar Status from the Foundation for Healthy Communities in 2009 and in the first quarter 2010.
• Patient’s Hospital Experience– SNHMC partners with Press Ganey  to survey patient satisfaction. We also participate in HCAHPS, which provides a standardized instrument and data collection methodology for measuring patients’ perspectives on hospital care. Many departments at The Medical Center also conduct point-of-service surveys to further understand patient needs and to craft services which meet those needs.

In addition, The Medical Center focuses on evidence-based practice in the following areas:

• Children’s Asthma Care – The Medical Center has 100% compliance in 2 out of 3 measures.
• Perinatal Care Quality Measures (NQF) – The Medical Center has achieved perfect compliance with 6 out of 16 measures.
• Stroke Care – The Medical Center received a Bronze Award for Stroke Care, based on exceeding 95% for 6 out of 7 measures, including 100% performance in 3 out of 7 measures. Our composite score tracked more than 4 points above all hospitals in the database and above hospitals that are designated by The Joint Commission as “Primary Stroke Centers.”
• Hospital Based Inpatient Psychiatric Services (HBIPS) – Our performance in this area meets or exceeds benchmarks for 6 out of 7 measures

Additonal Quality and Safety Initiatives

• Hand Hygiene – The Medical Center initiated a campaign to inform patients, staff, and visitors of the importance of hand washing. Click here for our results►
• Healthcare Associated Infections – The Medical Center has been working to eliminate hospital-acquired infections since 2001. Click on the following to see our recent results:

• C.difficile Toxin + Patients
• ICU Central Line Bloodstream Infections
• Surgical Site infections after Total Knee Replacement
• Surgical Site Infection after Colon Surgery
• Surgical Site Infection after Caesarean Section
• ICU Ventilator-Associated Pneumonia Rate
• Urinary Catheter-Associated UTI Rate       

For more information on national hospital data go to www.hospitalcompare.hhs.gov

For more information on national CMS data click here: www.qualitynet.org

A Culture of Safety

The hospital fosters a culture in which all of our staff and physicians are responsible for working with patients, families, and each other to ensure patient safety. We are proud to participate in national initiatives such as:

• Institute for Healthcare Improvement (IHI) 5 Million Lives

Click here to view our Institutes for HealthCare Improvement SNHMC 2010 Report Card

Medication Safety

Medication Safety is a priority for all of our clinical and administrative staff. Adverse drug events have been identified as the most frequent cause of patient harm in health care. For that reason we take part in the IHI’s 5 Million Lives Campaign initiative, “Prevention of Adverse Drug Events by Implementing Medication Reconciliation and Prevention of Harm from High Alert Medications.” Under the auspices of the Pharmacy and Therapeutics Committee, all medication events including near misses and errors are reviewed and analyzed. In 2009 alone, there were dozens of targeted initiatives to ensure evidence-based safety practices, including special procedures for insulin and insulin pumps, for antibiotics, for anticoagulants (blood thinners), and for narcotics and sedatives. Our goal is to provide the best possible drug therapy for each patient and to minimize the risks of all types of unintended drug effects.

National Best Practice for Perinatal Care

The BirthPlace team at Southern New Hampshire Medical Center completed a two year project with IHI's “IMPACT Learning and Innovation Community on Improving Perinatal Care.” The team focused on three main areas: Improving the Safety, Effectiveness and Reliability of Care; Increasing “Patient-Centeredness,” and Ensuring a Timely and Efficient System. Specific accomplishments included: working with Dartmouth to set standards for interpretation of Electronic Fetal Monitoring for physicians, midwives and nurses, simulation training for all providers and nursing staff, morning communication huddles for the entire team, and adoption of evidence-based order sets and checklists to ensure the best possible care.

In 2008, the National Quality Forum endorsed 17 perinatal standards related to care received by mothers and babies during the third trimester of pregnancy through hospital discharge. The goal is to eliminate all preventable harm from the childbirth experience for both mother and child.  A special interdisciplinary team at the Medical Center, the Maternal Child Health Care Council regularly examines Medical Center performance against all measures. The goal is to achieve the best possible performance in all process and outcome measures.