Metrics Evaluation (Ass 1) (1*)

Dignity Health Quality Transparency Dashboard for St. Elizabeth Community Hospital 1

Dignity Health Quality Transparency Dashboard for St. Elizabeth Community Hospital

Name

Institution

Date

Dignity Health Quality Transparency Dashboard

	CLABSI	COLON SSI	Low-risk Cesarean Rate	VTE	Sepsis Mortality
St. Elizabeth Community Hospital	N/A	N/A	11.00%	0.00%	7.10%
Measure period	01.07.2018-31.12.2018	01.01.2017-31.12.2017
California state level	0.82	0.96	13.00%	3.00%	14.90%
Measure period	01.07.2017-30.06.2018	01.01.2017-31.12.2017
National level	0.78	0.91	12.70%	2.00%	25.00%
Measure period	01.07.2018-30.06.2018	01.01.2011-31.12.2011	01.01.2017-31.12.2017

Note

Lower numbers are an indication of better care for the specific measure (dignityhealth.org, 2020)

St Elizabeth C-Section deliveries percentage rates as compared to the best and the worst performer nationwide.

Hospital	C-section	deliveries	percentage	performance
Sutter Davis Hospital	71	598	12%	Best
St. Elizabeth Community Hospital	54	210	26.2%	Below average
Monterey Park Hospital	205	495	41.6%	poor
Los Angeles Community Hospital	14	20	70%	worst

Note

Te national recommended percentage rate is 24%

To the director of safety compliance

I have reviewed the data obtained from the dignity health organization website as advised by your office regarding the compliance with Dignity Health Quality Transparency for St. Elizabeth Community Hospital. The report below is my evaluation of the data which indicates that there are areas that the organization performed extemporarily well and also areas that require improvement and the expected local state level and the national levels of performance benchmarks that the hospital is expected to achieve.

Overview of St. Elizabeth Hospital

The size of the facility

St. Elizabeth hospital has five facilities with a total of 25- bed critical access hospital located in Enumclaw, Washington, 1,250 total discharges, 5,593 patient days,

The specific type of care delivery

The hospital specializes in inpatient care for individuals with mental health problems ranging from acute to long term. Typically, patients in St. Elizabeth hospital have symptoms so severe and intense that security and the structure of the hospital are critical in assisting in the recovery from mental illnesses. The organization provides evaluations and recommendations to courts over suspects' competence to stand a legal trial.

The population diversity and ethnicity demographics

The organization is public and sponsored by the federal government. The hospital has passed from federal control to district government mental health services delivery facility. The facility serves the general public across the whole nation on a specialized basis. The service area has grown over time and much of the served population is both ethnically and racially diverse. The majority are aging patients as their need for mental health conditions get chronic.

The socioeconomic level of the population served by the organization

The hospital service area is small as compared to other Franciscan Health systems and serves residents with income below the poverty level is lower than the average of the Western Washington state region.

Evaluation of dashboard metrics

St Elizabeth hospital performances in considerable average in dignity health quality as dashboard measures indicated in Low-risk Cesarean Rate, VTE, and Sepsis Mortality. However, there was no data provided for CLABSI and COLON SSI.

CLABSI – Central Line-Associated Blood Stream Infection is an infection that occurs when germs or a bacteria finds its way into the bloodstream through the IV central line. This central line is critical in that it is the path that allows access to major veins to the heart and can stay in place for months or just a few weeks (Kramer, 2017). The line is used medically for administering medications and also for drawing blood for test reasons. The CLABSI is measured using the CDC and prevention of standardized infection ratio (SIR). The ratio indicates the number of infections per the number of the expected infections where values less than 1.00 indicate that the infections were above the expected measure. However, in this case, the scoring related to predicted infections was not availed.

COLON SSI – Surgical Site Infection from Colon Surgery occurs after surgery and is caused by bacteria after surgery is conducted. The infections are measured using the CDC SIR as well where the ratio indicates the number of the recorded infections per the number of the expected infections (Patel, Gupta, & Vaughn, 2018). A value of less than 1.00 indicates that the number of infections was lower than expected or that the ratio is within the set benchmark. In this case, the infection figures were not provided as indicated with N/A.

Low-Risk Cesarean Births indicate the safety measures that the health facility has put into place to ensure that the number of cesarean deliveries in low-risk pregnancies is reduced. The value indicates the number of surgical births per the total number of deliveries within the facility. The measures include all mothers whose deliveries were devoid of complications excluding the mothers who had twins, previous surgical births, and preterm deliveries which often require cesarean. A lower number than the expected benchmark indicates that the number of cesareans performed on low-risk mothers was few.

VTE – Preventable Venous Thromboembolism is a blood clot that results from a patient staying in beds for a long period. The health facility should ensure that effective and safe measures are put into place to prevent blood clots or treat them before they become an emergency issue. Patients at risk of VTE should be put under preventive measures during their hospital stays. VTEs are measured by the parentage of patients who experienced a blood clot in their hospital stay and failed to receive preventable treatment. A lower number, as it is the case in the dashboard is an indication of a better outcome.

Sepsis mortality or septic shock is the extreme body response to an infection. This shock is a life-threatening medical condition that all patients admitted to the emergency department face. The shock may result in organ failure, tissue damage, or even become fatal (Gaieski, Edwards, Kallan, & Carr, 2013). Sepsis is measured as a percentage of patients who died in the hospital and a lower number as it is the case in this dashboard indicates a better outcome.

The specific target for improvement and suggested actions

The data provided in the dashboard indicates that the hospital facility does not perform extemporary in Low-risk Cesarean Rate. According to the national hospital ratings in avoiding the C section St Elizabeth community hospital at 26.00%, the performance above the 24% state average. Although cesarean births can save lives for both the mother and that of the fetus, there are chances that the rapid rise over the past 20 years raises concerns over its misuse. Still, with the increase in the c section births, the maternal mortality rate in the US continues to rise.

The principle of beneficence including the non-maleficence affirms the ethical obligation that the healthcare professionals in the facility should employ to maximize benefits and minimize harm. Harm should therefore be allowed when the attempts to achieve the greater good to the concerns of the individual. Thus ethically, the medical practitioners are entitled to the obligation of minimizing harm while at the same time maximizing benefits.

The c section rate among the low-risk births in St. Elizabeth hospital indicates hospital and doctor practice patterns but not the health factors put into consideration by the hospital. There is an indication that the hospital midwives are not letting women labor longer enough before intervening. Thus there is the need for the hospital to avoid unnecessary indications, hire at least three midwives, promote a better understanding of fetal heart rate readings, letting labor start naturally. Women undergoing the first C section are three times more likely to die or suffer other complications such as anesthetic complications, massive breeding, infections and blood clot, and heart attacks.

There is also an indication that the hospital is adequately staffed with nurses and other medical practitioners. The hospital is also equipped with an adequate training program which is designed to introduce nurse and doctors to any emerging practice guideline. Formalized training and educating the staff should be upheld by the hospital management board to mitigate any possible challenges that might face the organization. However, data should be collected and recorded on Central Line-Associated Blood Stream operations since its unavailability indicates a lapse in the data recording system. Such a lapse may be technological, thus prompting the IT team to ensure that such records are updated daily.

Conclusion

Thank you for the opportunity and time. It is my sincere hope that this report has addressed key issues that you wished tackled from the obtained data. I am available for any further clarification and in case of any initiative to reinforce service delivery systems that can effectively shape the future of the organization. I would also be honored to participate in the development and revision of the practice guidelines that ensure proper patient care in the St. Elizabeth health facility.

References

dignityhealth.org. (2020, october). Dignity Health Quality Transparency Dashboard. Retrieved from dignityhealth.org: https://www.dignityhealth.org/my-home/%E2%80%9C/-/media/cm/media/documents/Quality%20and%20safety/September%202019/St%20Elizabeth%20Community%20Hospital.ashx'

Gaieski, D. F., Edwards, J. M., Kallan, M. J., & Carr, B. G. (2013). Benchmarking the incidenceand mortality of severe sepsis in the United States. Critical Care Medicine, 41(5), 1167–1174.

Kramer, R. D. (2017). Are antimicrobial peripherally inserted central catheters associated with reduction in central line–associated bloodstream infection? American Journal of Infection Control, 108-114.

Patel, P. K., Gupta, A., & Vaughn, V. M. (2018). Review of Strategies to Reduce Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) in Adult ICUs. Journal of Hospital Medicine, 105-116.