St. Mark's Hospital - October 22, 2018
by Debra Widmer, BSRC, HACP

Quality Director Debra Widmer, BSRC, HACP

The Quality team’s key focus continues to be sustaining the improvements that we have achieved through vigorous deployment of our Joint Commission Action Plan requirements. These efforts are led through ongoing leadership support, surveillance, education, accountability and the use of tools to support our directors with their priority goal, to maintain consistent survey readiness.

Eddie Decker, Patient Safety Director works to strengthen our safety culture. The volume of Serious Event reporting is improving and processes are enhanced through serious event analysis (RCA) that emphasize using a transparent and non-punitive approach for reporting and investigation. He also manages our risk, patient complaints process, and helps Kelsey with our mortality reviews.

Lindsay Snodgrass, Infection Prevention Manger has lead a collaborative effort to address infection prevention items that we were cited for during our 2017 Joint Commission survey. She is working to refresh staff’s knowledge about hospital acquired infections, general infection prevention practices, isolation precautions, high-level disinfection, and proper care of invasive devices.

Nathan Call, Quality Data Analyst, supports executive decision making through data analysis and facilitates process improvement efforts facility wide.

Desiree Duke, Stroke Program Coordinator, helps us to maintain our Primary Stroke Certification and focuses her expertise on facilitating the adherence to the Stroke Core Measures. The “Door to Needle Time” is a priority Core Measure to ensure that we deliver Alteplase to our patients who qualify in under 60 minutes from arrival.

Kelsey Dollar, Sepsis Coordinator, identifies a few key opportunities in the sepsis program. They are, Antibiotic administration in less than 60 minutes from sepsis symptom presentation, blood culture collection, repeat lactate labs and use of the Sepsis Order Set in EPIC.

Amy Lafleur, Chest Pain Coordinator, leads efforts to maintain our Chest Pain accreditation. Amy and her data abstractor, Melissa Johnson are focused on meeting all Core Measures in the discharge of cardiac patients by providing a checklist as a reminder for staff. Amy also works with our CVOR surgeons to highlight the documentation and process opportunities associated with the Society of Thoracic Surgeons (STS) National Database.

Merrilee Jensen, Perinatal Safety Coordinator, works with staff to promote accurate and timely documentation and evidence based practices that support exceptional outcomes for both the mom’s and babies. She provides concurrent review of charts for the five Perinatal Core Measures and Perinatal Data, which includes about 30 elements.

Gena Pierce is our Clinical Quality Specialist and is a consultant and process improvement expert on several projects. Most notably, the Cancer Studies that help us to maintain our Cancer Certification. She is also the quality consultant and data abstractor/analyst for the Transfusion Committee.

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