Our Improvement Plan

Jackson Hospital has identified six top priorities for hospital quality improvement for 2008. These are:

Raising Patient Satisfaction

• This is an overall measure of patients who reported yes, they would definitely recommend the hospital.
• Our most recent score was 78 percent of patients surveyed in the 2nd Qtr 2010. This compares to a nationwide average of 69 percent of all patients.

Our Improvement Initiative: We have created Team Camp Jackson, a patient satisfaction program that provides ongoing training for all employees in ways to go the extra mile consistently for every patient, every visit.

Average Minutes From Emergency Department Arrival to Receiving Balloon Angioplasty in Cardiac Emergencies

• Balloon angioplasty is usually the most effective treatment available during a heart attack. Jackson Hospital is one of only two hospitals in Central Alabama with this life-saving service. In heart attack patients, the longer that blood does not flow to the heart muscle, the more likely there is to be damage to that muscle. National agencies recommend that the waiting time for this treatment is less than 90 minutes. The percent of patients who received balloon angioplasty within 90 minutes January-June, 2010 was 100 percent.

Our Improvement Initiative: We are working this year to continue this performance by looking at all variations in our finely tuned emergency department and cath lab processes for opportunities for improvement.

Improvements in Stroke Care

• Nationwide, more than 700,000 people suffer from a stroke each year, making emergency stroke treatment a significant national priority. Jackson Hospital has recently become certified by the American Stroke Association as compliant with national guidelines in this area. Following a pre-established protocol, Jackson Hospital is currently averaging an overall score for following the recommended guidelines of 99%. The most important part of this protocol is to be able to administer (when clinically indicated) TPA, a medicine that can dissolve blood clots in the brain, within 180 minutes of the stroke event.

Our Improvement Initiative: In order to continue improvement with this important milestone, Jackson Hospital will provide publicity to educate the public about the warning signs of stroke, and will also work closely with area emergency and paramedic agencies.

Reducing Hospital-Acquired Infections

• For several years, Jackson Hospital has implemented a coordinated effort involving specially trained physicians and nurses in order to combat the serious issue of hospital-acquired infections. Although the overall rate of infections at Jackson Hospital is well below the predicted rate for the hospital (4.8%), we think that any infection is undesirable and we will work tirelessly on this issue as a major focus of the hospital's quality improvement program. The current rate of hospital-acquired infection markers is 2.2 percent for the 2nd Qtr 2010.

Our Improvement Initiative: Handwashing, being the most important infection prevention measure, is stressed to patient care staff and monitored for compliance with CDC guidelines.

Reducing Hospital Inpatient Falls

• Patient falls can be a problem for hospitalized patients. Disorientation from medication, illness or unfamiliar surroundings can put you at higher risk for falling. This can then increase the time you spend in the hospital rather than going home. The national benchmark for patient falls is 0.3 percent. At the end of the 2nd quarter 2010, Jackson Hospital is currently very close to the national benchmark.

Our Improvement Initiative: Jackson Hospital has created a falls reduction program and has implemented multiple measures to help identify patients at risk for falls and to continue to lower our falls percentage.

Improvements in Care for Patients With Pneumonia

• Community-acquired pneumonia is a serious infection of the lung, which can be caused by bacteria, viruses or other organisms. As one of the most common reasons for hospitalization in the U.S., medical studies have indicated that it is important to obtain a chest x-ray and blood culture lab test for patients suspected of having pneumonia. Once the diagnosis is made and the blood culture results are obtained, administration of antibiotics should begin as soon as possible. The national standard for completion of this treatment process is less than six hours from the time the patient presents at the emergency department. We are pleased to report that the percentage of patients who do obtain antibiotics within six hours is 100% for 2nd Qtr 2010.

Our Improvement Initiative: We will work to continue this performance by using methods to speed up the tests required for the emergency doctor to make a pneumonia diagnosis.