Quality & Patient Experience

The Quality & Safety Department at Speare Memorial Hospital strives to ensure the RIGHT care, is provided to the RIGHT patient, at the RIGHT time, with the highest level of patient satisfaction.

The Quality & Safety program at Speare is designed to produce favorable patient outcomes, increase the implementation of effective clinical care delivery processes, and meet the demands of state and federal accreditation entities. Principle components of the program include:

  • Implementing appropriate processes and technology designed to provide a safe environment for patient care delivery
  • Continuously pursue high levels of patient satisfaction
  • Achieving a “constant state of preparedness”

The QM Program must remain current and informed about the mandates of external accrediting entities, state and federal regulations (Condition of Participation), and their associated data submission requirements. Therefore, QM Program ensures that the alignment of operations and clinical services with these respective mandates ascribed to a Critical Access hospital.

  • Continuously monitor, assess, and improve Performance Management of each hospital department
  • Providing effective leadership and organization for hospital committees aimed to enhance care delivery services.
Patient Experience At Speare Memorial Hospital, our primary customers include our patients and their families. The QM Program diligently evaluates care delivery services and ways to improve customer satisfaction. In doing so, SMH partners with the nationally renowned company, Press Ganey , which specializes in administering, and reporting outcomes pertaining to patient satisfaction. Care delivery areas surveyed by Speare Memorial include:

  • Ambulatory Surgical Services
  • Emergency Room
  • Inpatient Services
  • Medical Practices
  • Outpatient Services (i.e. Laboratory, Radiology, Cardiac Rehab, Oncology, CardioPulmonary)
  • Urgent Care

The expectation of the QM department is that patient concerns and/or grievances are addressed in a thorough and timely manner. survey of patients experiences

Hospital Quality Data Quality Outcomes from Hospitalcompare.gov The Hospital Compare website provides, by hospital, outcome-based measures.  Below are a few examples of the timeliness of care and prevention effort outcomes at Speare. Quality Outcomes from Hospitalcompare Harm Events; although infrequent and unfortunate occurrences do happen in hospitals despite best efforts to provide safe, quality of care.  Preventing harm events in hospitals is a national and state effort. At Speare, we have chosen to participate in a national effort to reduce harm events sponsored by CMS/ Partnership for Patients and coordinated by the NH Hospital Association.  Speare is participating in its 7th year in the Partnership for Patients and is showing a continued downward trend in our preventable harm events.

Preventable harm events are considered the following:
  • Catheter-Associated Urinary Tract Infection
  • Central Line-Associated Bloodstream Infections
  • Surgical Site Infections
  • Serious Reportable Events
  • Falls with Injury
  • Adverse Drug Events with Significant Harm
  • Certain Events with Harm

reduction in preventable harm events by fiscal year Hospital 30-day all-cause inpatient readmissions.  Speare measures the readmission rate of all inpatients who are discharged and return within 30 days for any reason (all cause). 30 day readmissions fy 2018

Quality/Regulatory/Service Excellence Hospital Compare is a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients. This information can help consumers make informed decisions about where to go for health care. Hospital Compare allows consumers to select multiple hospitals and directly compare performance measure information related to heart attack, surgery, stroke care, ED throughput, disease-specific mortality outcomes, and other conditions. CLICK HERE for more information. Hospital Value-Based Purchasing (VBP) is part of the Centers for Medicare & Medicaid Services’ (CMS’) long-standing effort to link Medicare’s payment system to a value-based system to improve healthcare quality, including the quality of care provided in the inpatient hospital setting. CLICK HERE for more information. NH State Adverse Event Reporting: In 2010, the state of New Hampshire enacted RSA 151-38 which adopted the National Quality Forum’s Serious Reportable Events and added a specific event related to the transmission of blood borne pathogens. The law requires hospitals and ambulatory surgery centers to report any of these events should they occur in their facility. There are twenty-nine (29) NQF Serious Reportable Events (SREs) structured around six categories: surgical, product or device, environmental, patient protection, care management, and potential criminal. CLICK HERE for more information. Q-HIPThe purpose of the webtool is to collect and aggregate Q-HIP data. There are multiple data sources for Q-HIP, including data submitted by Q-HIP participating hospitals, Percutaneous Coronary Interventions (PCI) data from American College of Cardiology’s (ACC) National Cardiovascular Data Registry (NCDR®), Coronary Artery Bypass Graft (CABG) data from the Society of Thoracic Surgeons (STS), member satisfaction survey data from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS®) and readmission data from Hospital Compare. The Q-HIP Program Administration Vendor (PAV) will review and validate data from all sources and provide results in an aggregated format on the webtool. CLICK HERE for more information. Hospital Improvement Innovation Network This is a national initiative that SMH participates in to learn/adopt best practices in the pursuit of preventing harm events. New Hampshire Hospital Association: The NHHA vision is to be THE leading and respected voice for hospitals and health care delivery systems in New Hampshire working together to deliver compassionate, accessible, high quality, financially sustainable health care to the patients and communities they serve.  CLICK HERE for more information. Foundation for Healthy Communities is a non-profit organization that engages in innovative partnerships to improve health and health care in New Hampshire. Our work addresses quality of care, access to care and community prevention.  CLICK HERE for more information Press Ganey For more than 30 years, Press Ganey’s mission has been to support health care providers in understanding and improving the entire patient experience. As a strategic business partner to more than 26,000 health care organizations, we lead the industry in helping clients transform the patient experience and create continuous, sustainable improvement. CLICK HERE for more information State Operations Manual for CAH Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs) and Swing-Beds in CAHs CLICK HERE for more information. National Database of Nursing Quality Indicators® (NDNQI®) Nurses are at the forefront of the mission to reduce suffering and deliver patient-centered care. By providing a national database and RN surveys for examining relationships between nursing and patient outcomes, the  delivers evidence to support the importance of nurse sensitive measures in overall patient experience strategy.  CLICK HERE for more information
Infection Prevention Data A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place.  Speare Memorial Hospital monitors all surgeries with incision for SSIs using the National Health Safety Network criteria.  The Surgical Services staff work collaboratively with other patient care staff to implement programs and patient care procedures known to reduce surgical site infections. Another key way we prevent SSIs is by providing our patients with information about how they can take an active role in preventing infection in their surgical site surgical site infections
Quality & Safety Staff Melissa Howard, MHA, BS, RN, CPHQ Director of Quality and Safety (603) 238-6481 Sue Lopes, RN Quality Coordinator LauraLee Worthen BSN, RN Quality Coordinator (603) 481-8711 Erica Tuttle RN, CMSRN Infection Prevention Coordinator (603) 238-2156 You may contact us at: Quality & Safety Offices Speare Memorial Hospital 16 Hospital Road Plymouth, NH 03264
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