Quality and Patient Safety
Palmetto Health is committed to providing the highest possible level of clinical quality and patient safety. Through the efforts of our physicians and staff, we have significantly reduced harm events and mortality (we rank in the top 10 percent of all hospitals in the nation) and consistently achieve high scores in CMS Appropriate Care Measures. Our success has been remarkable but there is much more to do!
The following key activities are foundational to our overall quality and safety agenda.
Central line-associated bloodstream infections
- CL-BSI reduction activities include central line insertion bundle, daily needs assessment, preferred site selection, and house-wide surveillance for CLABSI.
- Unnecessary lines should be removed immediately.
CMS Appropriate Care Measures
- ACMs include acute myocardial infarction, heart failure, community-acquired pneumonia, stroke and surgical care.
- Each ACM has a set of best practices. Clinical data is extracted from the EMR for submission to CMS and The Joint Commission.
- Insulin is recommended for inpatients rather than oral agents.
- Glucose should be maintained between 140–160 mg/dL.
- MDRO reduction activites include isolation bundles and active MRSA screening for high risk patients. The isolation bundle includes use of personal protective equipment (PPE), correct transmission-based precaution sign, and an isolation order in the computer.
- Documentation of history of MDRO is located in the Cerner Problem List and Isolation Report.
- The patient's self-report of pain is the most reliable indicator of the existence of pain.
- The patient should be informed about potential limitations and adverse effects of pain treatment.
- Nursing staff is generally responsible for pain assessment and reassessment. Physicians will be contacted to re-evaluate pain management orders based on the ongoing assessment process.
- Timeout occurs just prior to the start of every procedure and involves the verification of the correct patient, correct side and site, correct invasive/surgical procedure, correct patient position, and as applicable any required implants and special equipment or requirements.
- The communication process must be active and include at minimum the surgeon, anesthesia provider, nurse and surgical technologist.
Abuse and Neglect
- Forms of abuse and neglect include abandonment, emotional, psychological, sexual, verbal, financial or material exploitation, and misappropriation.
- Report any suspected cases of abuse or neglect to social worker or case manager. If unsure of how to contact these personnel, contact your VPMA (hospital) or VP Clinical Affairs (ambulatory settings).
- These professionals will facilitate contact with SC DSS or other appropriate agency. However, this does not preclude mandated reporter's responsibility to report to the appropriate agency.