Our Pillars of Excellence - Quality

The Joint Commission

The Joint Commission evaluates and accredits nearly 15,000 health care organizations and programs in the United States. An independent, not-for-profit organization, The Joint Commission is the nation’s predominant standards-setting and accrediting body in health care. Since 1951, The Joint Commission has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by health care organizations. The Joint Commission’s comprehensive accreditation process evaluates an organization’s compliance with these standards and other accreditation requirements. Joint Commission accreditation is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. To earn and maintain The Joint Commission’s Gold Seal of Approval™, an organization must undergo an on-site survey by a Joint Commission survey team at least every three years. (Laboratories must be surveyed every two years.)

The Joint Commission National Quality Improvement Goals   Updated Jan. 2008

Reporting Period: July 2006 - June 2007
The Joint Commission only reports measures endorsed by the National Quality Forum.
Last Full Survey Date=Feb.11, 2007
DMH Fully Accredited—Accredited is awarded to a health care organization that is in compliance will all standards at the time of the on-site survey or has successfully addressed requirements for improvement within 90 days following the survey.

Heart Failure Care

DMH=This organization's performance is similar to the performance of most accredited organizations.
This category of evidence based measures assesses the overall quality of care provided to Heart Failure (HF) patients.

ACE inhibitor or ARB for LVSD
DMH=This organization's performance is similar to the performance of most accredited organizations.
Heart failure patients who receive a prescription for a medicine called an "ACE inhibitor" or a medicine called an angiotensin receptor blocker (ARB) when they are discharged from the hospital. Most patients who have heart failure and who take ACE inhibitor medicine have less symptoms, are physically better, and reduce their risk of returning to the hospital. The number of patients prescribed this drug is measured.

Adult smoking cessation advice/counseling
DMH=This organization achieved the best possible results.
Heart failure patients who are given advice about stopping smoking while they are in the hospital. This measure reports what percent of adult heart failure patients are provided advice and/or counseling to quit smoking. Smoking harms the heart, lungs and blood vessels and makes existing heart disease worse.

Discharge instructions
DMH=This organization's performance is above the performance of most accredited organizations.
Heart failure patients who receive specific discharge instructions about their condition. This measure reports what percent of patients with heart failure are given information about their condition and care when they leave the hospital. Patient education about medicines, diet, activities, and signs to watch for is important in order to prevent further hospitalization.

LVF Assessment
DMH=This organization's performance is above the performance of most accredited organizations. Heart failure patients who have had the function of the main pumping chamber of the heart (i.e., left ventricle) checked during their hospitalization.
This measure reports what percent of patients with heart failure receive an in-depth evaluation of heart muscle function in order to get the right treatment for their heart failure.

Pneumonia Care

DMH=This organization's performance is above the performance of most accredited organizations.
This category of evidence based measures assesses the overall quality of care provided to Pneumonia patients.

Adult smoking cessation advice/counseling
DMH=This organization achieved the best possible results.
Pneumonia patients who are given advice about stopping smoking while they are in the hospital. This measure reports what percent of adult pneumonia patients are provided advice and/or counseling to quit smoking. Smoking harms the heart, lungs and blood vessels and makes existing disease worse.

Blood cultures for pneumonia patients admitted through the Emergency Department.
DMH=This organization's performance is similar to the performance of most accredited organizations.
Pneumonia patients who were admitted through the Emergency Department who had a blood test in the Emergency Department for the presence of bacteria in their blood. Before antibiotics are given, blood samples are taken to test for the type of infection. This measure reports the percent of pneumonia patients admitted through the Emergency Department who received this test before antibiotics were given.

Initial antibiotic received within 4 hours of hospital arrival.
DMH=This organization's performance is above the performance of most accredited organizations.
Pneumonia patients who are given an antibiotic within 4 hours of arriving at the hospital. This measure reports the percent of adult pneumonia patients who are given an antibiotic within 4 hours of arriving at the hospital.

Initial antibiotic received within 8 hours of hospital arrival.
DMH=This organization's performance is similar to the performance of most accredited organizations.
Pneumonia patients who are given an antibiotic within 8 hours of arriving at the hospital. This measure reports the percent of adult pneumonia patients who are given an antibiotic within 8 hours of arriving at the hospital.

Oxygenation assessment
DMH=This organization achieved the best possible results.
Patients with pneumonia in which the amount of oxygen in the bloodstream was measured. This measure reports how many patients with pneumonia had their blood/oxygen level measured. Pneumonia reduces the amount of oxygen carried in a patient's blood.

Pneumococcal vaccination
DMH=This organization's performance is above the performance of most accredited organizations.
Pneumonia vaccination. This measure reports how many patients 65 years and older were screened and vaccinated to prevent pneumonia.

The Joint Commission National Patient Safety Goals

DMH’s performance is similar to the performance of most accredited organizations nationwide.

2007 Patient Safety Goal--Improve the accuracy of patient identification.
DMH=The organization has met the National Patient Safety Goal.
Organizations should use at least two patient identifiers (neither to be the patient’‘s room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures.

Improve the effectiveness of communication among caregivers.
DMH=The organization has met the National Patient Safety Goal.
For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

2007 Patient Safety Goal--Improve the safety of using medications.
DMH=The organization has met the National Patient Safety Goal.
Standardize and limit the number of drug concentrations available in the organization. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.

2007 Patient Safety Goal--Reduce the risk of health care-associated infections.
DMH=The organization has met the National Patient Safety Goal.
Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

2007 Patient Safety Goal--Accurately and completely reconcile medications across the continuum of care.
DMH=The organization has met the National Patient Safety Goal.
Implement a process for obtaining and documenting a complete list of the patient’‘s current medications upon the patient’‘s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. A complete list of the patient’‘s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.

2007 Patient Safety Goal--Reduce the risk of patient harm resulting from falls.
DMH=The organization has met the National Patient Safety Goal.
Implement a fall reduction program and evaluate the effectiveness of the program.

Encourage patients’ active involvement in their own care as a patient safety strategy.
DMH=The organization has met the National Patient Safety Goal.
Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

The organization identifies safety risks inherent in its patient population.
DMH=The organization has met the National Patient Safety Goal.
The organization identifies patients at risk for suicide.