McAlester Regional Health Center Quality Presentation
McAlester Regional Health Center aims to be the leading choice for medical care in Southeastern Oklahoma by focusing on quality outcomes, patient safety, excellent customer service, and financial sustainability. The center follows CMS regulations, maintains accreditation, and complies with ISO standards for continuous improvement and customer satisfaction.
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McAlester Regional Health Center Quality Presentation Revised 4/2020
MRHC Vision The McAlester Regional Health Center is the first choice for medical care in Southeastern Oklahoma
Objectives MRHC Critical Success Factors CMS Overview Discuss Hospital Accreditation Discuss ISO Compliance Review Process Improvement Review Primary Stroke Center Certification Discuss Public Reporting Review Clinic Quality Programs
Quality To be a top performer in clinical outcomes To obtain highest rating in patient safety Patient Experience Excellent Customer Service Low Cost, High Quality Care MRHC Critical Success Factors Brand Awareness Meeting community needs for Southeastern Oklahoma To be a provider of choice Financial Sustainability To have a strong balance sheet To have a strong credit rating Culture To have engaged employees To have engaged physicians To have accountability organization wide Individual and team compliance
CMS develops Conditions of Participation that health care organizations must meet in order to being and continue participating in Medicare and Medicaid programs CMS ensures that the standards of Accrediting Organizations recognized by CMS meet or exceed the Medicare standards set forth in the Conditions of Participation. The Centers for Medicare and Medicaid Services (CMS)
Accreditation DNV received CMS Deeming Authority in 2008 DNV believes in collaboration, encourage constant forward progress, and survey facilities on an annual basis Whitney Hull, RN, is MRHC s Quality Management Representative She can be reached via email at whull@mrhcok.com or via phone at extension 3952
ISO 9001:2015 is a Quality Management System that outlines basic good business practices that we need to have in place. ISO Compliance is required by DNV ISO 9001 ISO is a CULTURE of consistency, continual improvement, and customer satisfaction Document Control Internal Audits ISO Requirements Performance Improvement Projects Preventative/Corrective Action
Organizational Process Improvement
Serve as Process Improvement Projects organization wide, focused on Patient Experience, Quality, and Safety. The projects are department specific, geared toward the organization s overall strategic plan All team members of the department should be familiar with their projects and progress toward meeting goal at all times. Departmental Quality Boards
Primary Stroke Center
MRHC is a Nationally Accredited Primary Stroke Center, and a State Certified Level II Stroke Center Requirements of a Primary Stroke Center include but are not limited to: 24/7 brain imaging available Clot Busting medication, tPA, available to qualifying patients Physical Therapy, Occupational Therapy, and Speech Therapy onsite Contract with Regional Brain Institute for Stroke Neurology Consult via TeleHealth Transfer Agreements with Comprehensive Primary Stroke Center s MRHC has an Inpatient Rehab Facility, with a Medical Director who is a Neurologist that specializes in Neurorehabilitation All MRHC employees are educated on F.A.S.T (quick recognition of a stroke) All nurses and doctors caring for stroke patients are NIHSS Certified Tammy Barnette, RN is MRHC s Stroke Coordinator She can be reached via email at tbarnette@mrhcok.com or via phone at ext. 6978 if you have any questions regarding Stroke at MRHC
Hospital Compare has information about the quality of care for Medicare- certified hospitals. Consumers can use Hospital Compare to find hospitals and compare their quality. Consumers can see data related to: General Information about Hospital Patient Experience Timely & Effective Care Complications & Death Unplanned Hospital Visits Payment & Value of Care Public Reporting
Clinic Quality Reporting Programs Partners in an Accountable Care Organization Participate in Comprehensive Primary Care Plus Both of these Quality Programs focus on Population Health, preventative care, and cost reduction for Primary Care Patients.
Closing Thoughts- In 1962, President John F. Kennedy visited NASA for the first time. During his tour of the facility, he met a janitor who was carrying a broom down the hallway. The President then casually asked the janitor what he did for NASA, and the janitor replied, I m helping put a man on the moon. To the naked eye, this janitor was just cleaning the building, but in the more mythic, larger story unfolding around him, he was helping put a man on the moon. Here s the point: No matter how large or small your role, you are contributing to the larger story unfolding within your life, your business and your organization. And when your entire team embraces that type of attitude and belief system, incredible things happen.