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Quality Management
QUALITY AND PATIENT SATISFACTION
 Patient safety and customer satisfaction are our primary considerations. The Board-of-Directors has the ultimate responsibility and accountability for the quality patient safety and customer satisfaction are our primary considerations. The board-of-directors has the ultimate responsibility and accountability for the quality of care and services provided by the Hospital. Through their leadership, the Hospital has adopted a continuous quality improvement philosophy and has empowered a multilevel, interdisciplinary quality council to oversee performance improvement activities for all departments and services. The purpose of continuous quality improvement is to improve the care of our patients.
Holy Cross Hospital strives to put its mission/vision into practice using research-based best practices and systematic performance improvement strategies identified by our own physicians, employees, patients and families. Organization-wide sharing of information about Hospital performance is encouraged and is expected.
Holy Cross Hospital believes it will maintain the highest level of service through a customer focus. Holy Cross Hospital will continually strive to exceed the expectations of quality patient care and safety. Quality is enabled through utilization of the Crew Resource Management Model (LifeWing’s Program) through effective communication systems, team building, process improvement, patient safety tools and an empowered workforce.
Holy Cross Hospital utilizes the LifeWing’s Program to implement safety tools and standardize policies and procedures that make patient safety an absolute requirement and a cornerstone of quality patient care. LifeWings’ Committees play an active role in every clinical department. Physicians along with department staff develop policies and guidelines addressing patient care and safety issues that are identified by the team or by the process improvement system in the Hospital.
Holy Cross Hospital, along with every other health care institution in the country, is challenged with improving processes and eliminating waste. This includes how patients are treated and managed from admission to discharge. Outcome measures for major conditions are monitored and reported to the board, medical staff, and employees. Based on the results of these measures we change processes in order to continuously improve and do better. However, just because we are doing better does not mean we do not keep looking at ways we can continue to improve.
Holy Cross Hospital has been increasingly improving our clinical care scores since 2006. The following charts show how Holy Cross Hospital has performed yearly since 2006 and how we compare to other hospitals in New Mexico and in the US. Each chart represents the number of times every aspect of care was performed perfectly and documented correctly for patients coming in to the Hospital for care during a heart attack, with pneumonia or congestive heart failure, or for surgical procedures. Indicators we use are:
- Did the patient receive the correct medication within 60 minutes of arrival to the hospital?
- Were the correct lab tests ordered?
- Did the patient receive advice on diet, exercise, life style changes and smoking cessation when he/she was sent home?
- Was the correct antibiotic given at the appropriate time prior to surgery in order to decrease risk for infection?
The Medical Staff and the Hospital Governing Board are very involved in assuring that the hospital meets and exceeds the expectations for clinical quality expected by our community and by the governmental agencies who oversee our provision of care.
The Quality Council is a group of physician leaders and senior leaders whose role it is to review the processes in place to assure compliance with accepted standards of care and to recommend and enforce necessary changes in order to meet those standards. The goal of the Quality Core Team is to promote a culture and system of Quality Improvement and to engage physicians and senior leadership in developing a strategy by which quality initiatives and improvement issues are addressed. |
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