apexawardnov2011f.pdf • 2011 VHA Pennsylvania APEX (Achieving Patient Care Excellence) Award – eliminating Foley Catheter Related Urinary Tract Infections for a consecutive 12-month period hospital wide (the APEX criteria require a 6-month period), from July 1, 2010 through June 30, 2011- November   2011APEX Award  

• Jameson Hospital Awarded the Joint Commission Gold Seal of Approval - October 2011By meeting the explicit national standards for health care quality and safety, Jameson Hospital has been recognized by The Joint Commission, the leading accreditor of healthcare organizations in the United States, with a Gold Seal of Approval for the Hospital Accreditation Program and Home Care Accreditation Program of Jameson Hospice for a 36-month period beginning July 2011. The Joint Commission is an independent, not-for-profit, national body that oversees the safety and quality of health care in accredited organizations, evaluating and inspiring them to excel providing safe and effective care of the highest quality and value.    
Joint Commission Gold Seal of Approval  
Jameson Hospital
Jameson Hospice 

• Jameson's Maternity Care Center Ranks "Highest" Nationwide. For the first quarter of 2011, The Maternity Care Center at Jameson ranked in the 99th percentile out of 1,759 hospitals nationwide for patient satisfaction and experience ratings.  When asked what sets Jameson’s Maternity Unit apart from the other obstetrical units in the country, Madeline Melidona, the unit’s Patient Care Manager responded, “It’s our people. The doctors, the nurses and staff make the experience wonderful by informing the mothers and making them feel safe at all times. I am grateful to work with such a wonderful group of individuals.” A previous patient of Jameson’s Maternity Care Center, Elizabeth Ernst, resident of Union Township and Spanish Teach at Laurel High School, commented, “Our experience at Jameson was phenomenal. The care of the entire nursing staff was genuine and our comfort was their top priority. Each nurse had a unique suggestion that helped to put us at ease as we learned how to take care of our newborn.” 

• Jameson Hospital Receives "Maximum Achievement Level" for Highmark QualityBLUE - including a score of 100% on "Surgical Safety" Initiative.  Highmark QualityBLUE commended Jameson Hospital for achieving the Maximum Achievement Level on selected QualityBLUE projects including: inpatient diabetes management, Venous Thromboembolism Prophylaxis (VTE), ED Throughput and Surgical Safety. An additional honor came in the form of achieving a score of 100% on the Surgical Safety initiative where the team created and successful implemented new processes to promote positive clinical outcomes to further improve and develop patient safety in our hospital. By receiving 100% on their initiative, the team will be asked to share their program at a best practices forum with other regional hospitals participating in the Highmark QualityBLUE pay-per-performance program.

• Jameson Hospital Recognized as a Community Value Five-Star Hospital
 Jameson Hospital has been recognized as a Community Value Five-Star hospital by Cleverley & Associates, a leading healthcare data firm specializing in operational benchmarking and performance enhancement strategies. The CVI is composed of ten measures that assess a hospital’s performance in four areas:  financial viability and plant reinvestment, cost structure, charge structure and quality performance. Fundamentally, the CVI suggests that a hospital provides value to the community when it is financially viable, is appropriately reinvesting back into the facility, maintains a low cost structure, has reasonable charges and provides high quality care to patients. Measurement in these areas suggest that hospitals operating with a high degree of community value are those that are low cost, low charge and use a strong financial position to reinvest back into the provision of care at the facility.  Each area contains metrics that compare a hospital’s performance to an appropriate peer group. The combined performance in each area is the Community Value Index TM score.  Hospitals such as Jameson, with scores in the top twenty percent are designated as “Five-Star” facilities.   

• 2010 VHA Pennsylvania APEX (Achieving Patient Care Excellence) Award for Excellence in Patient Care for Central Line Associated Bloodstream Infections (CLABI). The award was presented to Jameson Hospital in October, 2010 for demonstrating extraordinary levels of clinical performance by eliminating blood stream infections for a 15-month period hospital wide (the APEX criteria requires a 12-month period), from April 1, 2009 through June 30, 2010.

• 2010 Highmark QualityBLUE  awarded Jameson Hospital Maternity Care Center the Perinatal Award for Overall Highest Rate of Compliance with the Elective Induction Bundle for the Program Year

• Highmark QualityBLUE commended Jameson Hospital for their creation and successful implementation of new processes to promote positive clinical outcomes to further improve and develop patient safety initiatives earning a score of 96 percent thereby earning the Maximum Achievement Level for Fiscal Year 2010 meeting 100% of Pennsylvania state averages for applicable Centers for Medicare & Medicaid Services (CMS) Quality Core Measure performance.

• Increased Emergency Department efficiencies – “ED Throughput”
• Reducing hospital acquired infections
• Implementing an antimicrobial stewardship program
• Improving venous thromboembolism (VTE) prophylaxis compliance
• Decreasing the number of deliveries less than 39-weeks gestation.

Mary Blank, Manager, Highmark Hospital Performance Management commented, “Congratulations for a very successful performance year.  We applaud your hospital team efforts and continued commitment to improving patient care.”

The Highmark QualityBLUE Pay-for-Performance Program began in 2002 with six hospitals. Today, 29 hospitals participate in the program in Western Pennsylvania and the program was recently expanded to include one hospital in Central Pennsylvania. Further expansion is projected.

Douglas Danko, Jameson Health System President/CEO said, “Jameson is committed to advancing a culture of quality.  I commend the members of the QualityBLUE Team in their efforts and continued commitment to improving patient care on a daily basis.”

These specific measures show the program is progressive.  The QualityBLUE program is making a difference when it comes to quality care.  Jameson Hospital and other hospitals in the program are safer with significant cost savings. 

• VHA Leadership Award – Cardiac Care Excellence

• VHA Certificate of Excellence – Congestive Heart Failure Core Measure Indicators

• VHA APEX (Achieving Patient Care Excellence) Award – eliminating Symptomatic Catheter-Associated Hospital-Acquired Urinary Tract Infectionsfor several periods from April 2008 through June 2009

• VHA APEX (Achieving Patient Care Excellence) Award – Cardiac Care Excellence

• Western Pennsylvania Council Safety Award

• CMS Quality Measure Performance – 99.37%

• Best Practice Award Risk Management Program for:

• Maternity Care Center’s code for rapid simultaneous activation of the OB team during emergency obstetrical situations
• Transportation Safety Form to communicate information to staff when patients are transferred to departments or outside of the hospital
• Use of Root Cause Analysis process for potentially serious events
• Credentialing Process used to establish criteria when physicians request to perform a new procedure or treatment
• Infection Control Rate

• Quality Management Services Highmark QualityBLUE Team earned score of 99.37% attaining Maximum Achievement Level for fiscal year 2009 meeting 100% of PA state averages for applicable CMS Quality Measure performance: 

• Conducted training to teach staff how patients obtain and how to prevent CAUTIs (Catheter Associated Urinary Tract Infections), thus reducing UTI rate by more than 50%
• Improvements included reduction of MRSA (Methicillin-resistant Staphylococcus aureus), launch of SCIP (Surgical Care Improvement Project) and improvement in CLAB (Central Line Associated Blood Infections)

• 2009 VHA Pennsylvania APEX (Achieving Patient Care Excellence) Award for greatest improvement in CAUTI, MRSA, SCIP and CLAB

• Risk Management earned Best Practice Awards for Maternity Care Center code for rapid simultaneous activation of the OB team during emergency OB situations; transportation safety form and use of Root Cause Analysis process

•  Information Management recognized as 3M case study in 3M  Navigator for transitioning to Electronic Medical Record and improving access to patient information for care providers improving compliance with HIPAA regulations, legal record requirements and replacing costly paper-based sources.