Quality Care Measures

St. Michael’s Hospital is committed to providing high-quality care for all the health care needs of you and your family. Our staff places high priority on providing quality care and ensuring safety for our patients and residents. We ask you and your families to join us to make sure that our care meets your needs and encourage you to let us know when it does not.

Research indicates that individuals who are involved in their care feel safer, have better results and are more satisfied. To become more involved in your health care, we recommend the following:
1. Speak up and ask questions if you do not understand or have concerns.
2. Share your health information with us, so we can better understand your needs.
3. Make sure your health care providers confirm your identity by asking your name and checking your wrist band before giving medications or doing a procedure
4. Expect your health care providers to introduce themselves. Look for their name badge.
5. Know the medications you are taking, the reason, the times and any side effects.
6. Tell your physician and nurse about the medications you take, including vitamins, herbal supplements and over the counter drugs.
7. Tell your health care providers of any drug, food, or latex allergies.
8. Encourage hand washing for yourself, visitors and all health care providers during your stay.

St. Michael’s has an established Quality Assurance Committee made up of the Quality Assurance Coordinator, Medical Records Supervisor, Pharmacist, Director of Nursing, Safety Director, Administrator and Physician representative. Other members are appointed by the Administrator.

The Nursing Home Medical Staff actively participates in quality/risk management activities directly associated with clinical aspects of care.

The Governing Board has the final authority and responsibility for the implementation and monitoring of the quality/risk management program.

Quality Assurance Committee Goals
The quality assurance committee’s goal is for everyone in the organization to support a system of performance measurement, assessment and improvement. To accomplish this, the committee will:
• Assure that monitoring activities are consistent with our mission statement and the quality/safety goals.
• Review quarterly performance data from department directors, contracted services, and medical staff.
• Receive and evaluate suggestions for improvement from medical staff, employees, and customers.
• Ensure that when an opportunity for improvement is identified it is referred to the appropriate department.
• Educate staff on quality/risk management goals and activities.
• Coordinate activities with the Safety Committee.
• Comply with Minnesota Department of Health and other regulatory/accrediting regulations.

Accomplishments
Examples of the Quality Assurance Committee’s accomplishments include but are not limited to the following:
• Patient Identification: developing a facility wide policy for the use of two patient identifiers prior to medication administration or procedures.
• Limiting the use of abbreviations: developing a DO NOT USE list of abbreviations
• Evaluating High Risk Medications and look alike medications to improve safe processes when working with these medications
• Improve the informed consent process
• Implementing the Minnesota Hospital Association’s SAFE SKIN Initiative to prevent pressure ulcers.
o St. Michael’s Hospital was recognized by the Minnesota Hospital Association for their implementation of this program
• Implementing the Minnesota Hospital Association’s SAFE from FALLS Initiative to help patients avoid falling
o St. Michael’s Hospital was recognized by the Minnesota Hospital Association for their implementation of this program
• Implementing the Minnesota Hospital Association’s SAFE COUNT Initiative to provide excellent care in obstetrics
o St. Michael’s Hospital was recognized by the Minnesota Hospital Association for their implementation of this program
• Participation in the Minnesota Hospital Association’s Patient Safety Registry
• Participation in the Institute for Health Care Improvement’s 5 Million Lives Campaign