Quality & Safety
At Enloe Medical Center, we take quality and safety seriously.
We not only provide compassionate care to our patients, but we continuously
look for ways to improve the care we provide. Embraced by our medical
staff leadership and management team, quality and performance improvement
are strategic initiatives threaded throughout our entire organization
-- from the Board of Trustees to our Board Quality Committee to
our Quality Leadership and Administrative Quality Councils, our
medical staff peer review and Patient Relations Program. Through
our Patient Relations Program, we are able to regularly assess our
patients' experiences and comments and make appropriate modifications
to improve the care we provide.
We participate in a number of quality assurance initiatives and
publicly released surveys including:
- Review by Joint Commission on Accreditation of Healthcare Organizations
- Risk-adjusted database survey by the Society for Thoracic Surgeons
- Participation in the CHART Quality Measurement Reporting program
to develop a public report card on hospital quality measures
- The California Coronary Artery Bypass Graft Mortality Reporting
Program, a joint-effort survey of the Office of Statewide Health
Planning and Development (OSHPD) and the Pacific Business Group
on Health (PBGH)
- Participation in the Institute for Healthcare Improvement’s
“100,000 Lives Campaign” to adopt “Best Practices”
in several areas of hospital procedures
- The Enloe Heart Program joins most other major cardiac surgery programs in the nation in participating in a surgical outcomes database managed by the Society of Thoracic Surgeons (STS). STS is widely regarded by clinicians as the most comprehensive and conclusive tool for comparing cardiac surgery results.
- The Enloe Heart Program reports outcomes of cardiac artery bypass graft surgeries to CCORP (California CABG Outcomes Reporting Program) semi-annually, as is required by law in California.
- Enloe Medical Center's Outpatient Diabetes Education program is recognized by the American Diabetes Association for meeting National Standards for Quality Self-Management Education.
On an ongoing basis, we evaluate how our care and health outreach
benefits the health of our community, and determine how
to improve and extend the health services we offer. To learn more,
read out our Community Benefit
Plan.
Safety from infection
Infections are a problem at hospitals, and in communities, throughout the country. Hospitals can easily become a hotbed for germs because we take care of very sick people, many of whom arrive with communicable diseases.
- Nationwide, infections acquired in hospitals and the community alike are increasing and becoming more difficult to treat due to the overuse of antibiotics.
- Many times patients think they acquired an infection in the hospital when that is simply not true. An infection is considered community acquired if it is present or incubating on admission.
- About 30 percent to 50 percent of healthy adults and children carry staph bacteria at various times without getting sick. Most of us begin to have staph bacteria growing harmlessly on our bodies before we are one week old.
At Enloe, we take infection seriously. The infection and quality programs that we participate in include:
- Enloe is a voluntary participant in the California Nursing Outcomes Coalition’s (CalNOC’s) statewide annual prevalence study for decubitis ulcers (bedsores). This annual study helps us to measure our effectiveness and make improvements in our monitoring program to prevent decubitis ulcers.
- Enloe participates in the Institute for Healthcare Improvement’s “100,000 Lives Campaign” to adopt “Best Practices” in several areas of hospital procedures, including ventilator-associated pneumonia and rapid response team.
- Enloe is participating in CHART Quality Measurement Reporting. This California Hospital Association program will develop a public report card on hospital quality measures.
- Enloe provides ongoing education of medical and nursing staffs regarding identification and treatment of specific types of infection.
Enloe has in place rigorous infection control policies and procedures.
Infection control practices are guided by an infectious disease expert and supported by a nurse manager specially trained in infection control practices. We continually strive to protect our patients from infection. We will continue to support national, state and regional efforts to improve quality of care for patients.
Enloe will continue important precautions already in place, which include:
- Routine daily practices when working with patients and instruments
- Removal of carpet, where bacteria can linger, from all inpatient rooms
- Continued use of alcohol-based waterless handwashing gel
- Improved management of diabetic and pre-diabetic blood sugar levels to promote better healing.
- The use of several quality watch committees, including:
- Board of Trustees’ Committee on Quality
- Quality Management Council, which oversees all Medical Staff issues
- Administrative Quality Council, which addresses medical and operational issues
Enloe Medical Center has been recognized for its high quality of patient care, specifically in the area of controlling hospital-acquired infections.
- Nationally, the Institute for Healthcare Improvement cites surgical infection rates nationwide of 2.6 percent of nearly 30 million operations annually. Enloe’s rate of 1.34 percent in 2005 compares favorably to this national data.
- Enloe has deployed new software called MedMined, which uses Data Mining Surveillance technology to identify where and when infections may originate early enough for hospital staff to change their practices to reduce unnecessary illness, length of stay, cost and most importantly, death. Enloe is one of only 11 hospitals in the state selected by Blue Shield of California Foundation to receive a $90,000 grant to participate in a demonstration program aimed at preventing hospital-borne infections. Our hospital is looked to for Best Practices by other hospitals in this initiative.
At Enloe, we believe one infection is one too many.
While we have a good record overall on hospital-acquired infection, we continue to be vigilant in fighting infection. We constantly review and tighten our infection control policies and practices. And, like all hospitals, we are subject to regular and unannounced reviews by the Joint Commission on Accreditation of Healthcare Organizations, the Centers for Medicare and Medicaid and the California State Department of Health Services. At Enloe we will continue to strive for zero hospital-acquired infections at our hospital.
Patient involvement
Patient safety is our first priority here at Enloe. Everyone involved in patient care has a role to play in safety - including patients themselves. Research shows that patients who take part in their health care decisions have better outcomes. There are simple steps patients can take to become an informed member of their health care team. Check back for further updates to this information.
Speak up: You have a right know about your health care and any inherent risk. Bring written questions to your doctor appointments so you can get each one addressed. Be honest and complete about your condition; withholding information can lead to unintended errors. Speak up if you do not fully understand your doctor or nurse or if something seems wrong. No news isn’t necessarily good news; ask when you will get test results. Expect health care workers to introduce themselves and identify you. Know which medication or treatment a nurse is giving. Is it yours? Did the nurse check your ID band before giving it? They should every time. Speak up if they don’t. This can prevent errors. Also, it's OK to ask if your caregiver has washed his or her hands. Handwashing is the single best way of preventing infection.
Educate yourself:Ask for patient brochures on your tests and diagnosis and take notes when you talk with your doctor. If you don’t understand you’re the star everything, ask questions until you do. Don’t be afraid to ask about your doctor’s experience with the care you require. Seek a second opinion. It’s not an insult to the doctor; more information helps you make better decisions. Ask for reliable web sites where you can learn more.
Ask for help: Consider having a trusted friend or family member accompany you to medical appointments or the hospital. It is difficult enough to understand complex health care explanations, and it only gets harder when it involves – you! Review questions and concerns with your advocate and ask that he or she bring up anything you leave out or other questions that come up. No question is too silly when it comes to your health care. Make sure your advocate knows your wishes about resuscitation and life support.Safe patient care requires careful planning. The single most important way you can help prevent errors is to be an active member of your health care team.
If you have concerns
If a patient/designated representative wishes to file a complaint/grievance, they may contact the Patient Relations Coordinator at (530) 332-7005. This line is accessible 24 hours a day. Complaints may also be filed with the Department of Health Services, by calling 1-800-554-0350. The local Department of Health Services office is located at 1367 East Lassen Avenue, Suite B1, Chico, CA 95973. Any concerns about patient care and safety in the hospital that the hospital has not addressed may be sent to the Joint Commission on Accreditation of Healthcare Organizations by calling 1-800-994-6610 or e-mailing complaint@jointcommission.org.
Additional patient resources
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