Performance Improvement in Hospitals

PERFORMANCE IMPROVEMENT IN HOSPITALS

The Joint Commission on Accreditation of Health Organizations (JCAHO) establishes standards for health organizations that cover a wide spectrum of operations and responsibilities. To be accredited by the JCAHO, a health organization must be rated satisfactory on an assessment of the organization conducted by JCAHO. This assessment covers all JCAHO standards. Assessments are conducted through an on-site survey of a health organizations operations and responsibilities.

The principal focus of all standards developed for the JCAHO is supposed to be on the patient. While the specifics of a standard for a particular performance area may emphasize the clinical or operational aspects of that performance area, the ultimate intent of the performance standard, according to JCAHO, is the outcome for the patient.

According to the information provided by Joint Commission, Elmhurst Hospital Center was accredited in 2011, however, JACHO found a deficiency in the performance on patients who had blood cultures for pneumonia when admitted through the Emergency Department (ED). Before a patient receives any antibiotics for pneumonia, it is important that blood culture be taken to test for the type of infection present so it is treated properly. This measure reports that the average rate for this performance is 95%, but Elmhurst Hospital Center only reached 91% of 230 eligible patients. This percentage is below the benchmark for this standard. Elmhurst Hospital Center has to improve this area of performance and we have developed task force to analyze our needs, implement correcting actions and monitor our progress in this area over the next six months. Blood cultures are routinely obtained in the ED before antibiotic administration, and often before a decision has been made whether to admit a patient. This practice is both to JCAHO and Centers for Medicare and Medicaid Services CMS quality measures for pneumonia that emphasize performing...