Quality and Safety

At Providence Saint Joseph Medical Center, our goal is to become a regional leader in health care quality and safety. For many measures, we are already there. For other measures, we have concrete plans in place to improve.

We are working hard to improve our rates of hospital-acquired infections, avoiding Methicillin-resistant Staphyloccus aureus (MRSA) infections, central-line infections, catheter-urinary tract infections and surgical site infections. We have a robust surveillance system that allows us to identify infections better, and we actively go looking for certain infections through surgical case reviews.

Like most healthcare institutions, we are striving to improve, and remain confident we will continue to reduce infections and improve patient safety every day.

Some examples of our efforts have already resulted in significant quality and safety improvements for our patients:

Falls Prevention Initiative

Providence Saint Joseph Medical Center initiated a comprehensive falls prevention program, designed to reduce the number of patient falls throughout the medical center. Since its inception in 2014, we’ve seen an 85.7% decrease in moderate to severe injury falls.

Our Total Falls incidence per 1000 patient days has been below the California state benchmark for the past five quarters. Strategies that we use in decreasing falls are as follows:

  • Patients who are at high risk for falls are provided with red socks and signs are posted outside their rooms, alerting caregivers of fall risk.
  • Bed alarms are used to alert caregivers to potential fall activity. Caregivers conduct hourly rounding to check the alarms, ensuring patient safety.
  • Care of patients is everyone’s responsibility. All caregivers are committed to responding to alarms and call lights when passing through patient areas, creating a “no pass zone”.  

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High Reliability Organization (HRO) Training

As Providence Saint Joseph Medical Center caregivers, our greatest responsibility is the safety of our patients and each other. In order to provide compassionate, safe, and high-quality care every time, we have embarked on a journey toward a culture of “High Reliability.” The first step in this journey is for all of our caregivers to attend an in-person “High Reliability” class.  These classes are taught by a select group of PSJMC caregivers who have been trained in HRO materials. The content includes the science behind safety as well as techniques and behaviors that have been proven to reduce error and improve safety in high-stress environments, like the airline industry, the nuclear industry, and healthcare.

To date, 90% of our caregivers and 52% of our professional staff have attended HRO training. Our goal is to have 100% of our caregivers and professional staff trained by the end of 2017. 

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Readmission Reduction Program

PSJMC’s goal is to provide patient support, and maintain patient health in the community. For this reason, we have launched several strategies to lower the 30-day readmission rate. According to the latest data, our Heart Failure Readmission observed rate dropped from 19.75 to 15.60, a 21% decrease from 2016 to Q1’2017. The Chronic Obstructive Pulmonary Disease (COPD) rate has decreased by 54% for the same time period.

The strategies for readmission reduction focus on ensuring that patients and families are being educated on instructions for after discharge care. Our caregivers educate the patient, and ask the patient, caregiver, or family member to repeat the care instructions in their own words. In addition, our hospital pharmacists provide education to patients, help answer questions on new medications or medication that the patient will continue after discharge. Our care team ensures that the patient has a follow-up appointment made, within 14 days of discharge, with the primary care physician.

This site shows where we’re doing great, and where we can perform even better. The site also offers important information about quality care, quality measures, and what quality really means to the most important people in our community: you – our patients and families. While quality reports from other sites may be a year old or more, the reports on our website show the most up-to-date measures of quality and safety at Providence Saint Joseph Medical Center.

Explore these pages and learn more about how we engage in quality and safety 24 hours a day, seven days a week!


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