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Quality Indicators

Quality Indicators at St. Joseph's Hospital
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To see St. Joseph's data in comparison to the state and national average please review at

A Commitment to Patient Safety at St. Joseph's

The Joint Commission on Hospital Accreditation has set specific goals to improve the safety of patients.

Joint Commission National Patient Safety Goals 2010.

1. Improve the accuracy of patient identification

Use at least two patient identifiers when providing care, treatment, and services.

2. Eliminate transfusion errors related to patient misidentification.

Before initiating a blood or blood component transfusion, the patient is objectively matched to the blood or blood component during a two-person bedside or chair-side verification process.

3. Improve the effectiveness of communication among caregivers.

For verbal or telephone orders or for telephone reporting of critical test results, the individual giving the order or test result verifies the complete order or test result by having the person receiving the information record and "read back" the complete order or test result.

4.The organization measures, assesses, and, if needed, takes action to improve the timeliness of reporting and the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver.

5.Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

6. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function related to a healthcare-associated infection.

Reduce the risk of health care associated infections. Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

7. Accurately and completely reconcile medications across the continuum of care. A process exists for comparing the [patient]'s current medications with those ordered for the [patient] while under the care of the organization

8. Reduce the risk of patient harm resulting from falls. The organization implements a fall reduction program that includes an evaluation of the effectiveness of the program.

9.Encourage patients' active involvement in their own care as a patient safety strategy. Identify the ways in which the patient and his or her family can report concerns about safety and encourage them to do so.

10.The organization identifies safety risks inherent in its patient population. The organization identifies patients' at risk for suicide.

Note: This requirement only applies to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.

11. Improve recognition and response to changes in a patient's condition. The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient's condition appears to be worsening.

12.The organization meets the expectations of the Universal Protocol for invasive procedures.

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