Patient Safety and Quality Care
At Simi Valley Hospital, nothing is more important to us than providing quality care to our patients in a safe and nurturing environment. It is our reason for being. In every encounter with every patient at Simi Valley Hospital, our focus is on achieving the highest level of clinical quality and safety.
We are proud of our staff for the compassionate and personalized care they provide. This is a hallmark of Simi Valley Hospital. Ultimately, however, we know that it is the quality of care and a safe environment that best serve our patients and our community. That is why everything we do is driven by our commitment to quality and safety.
Our standards for clinical quality flow from the evidence-based best practices of medical facilities nationwide. These best-practice guidelines are designed to minimize variation in our clinical processes and improve outcomes for our patients.
Working in conjunction with Adventist Health, our parent company, we set yearly patient safety goals and create plans — at both the corporate and local levels — to meet or exceed these goals. But reaching our performance goals are not ends in themselves; we do this because of our unwavering commitment to providing the highest-quality service and safest possible environment for our patients and visitors.
Simi Valley Hospital is accredited by The Joint Commission, an independent, not-for-profit organization that is among the most prominent accrediting bodies in the health care industry.
Our most recent on-site survey by The Joint Commission occurred in July 2010. During the four-day visit, a team consisting of an RN lead surveyor, a second RN surveyor, an engineer and a physician surveyor from the Institute for Medical Quality conducted a thorough examination of our records and interviewed a number of hospital staff members. As a result of that visit, we received the organization’s maximum three-year accreditation.
Simi Valley Hospital works closely with Adventist Health — our parent company — and other hospitals in our system on several programs aimed at improving quality and patient safety throughout our four-state system. The following is an overview of some of those initiatives.
CULTURE OF SAFETY
To bolster Simi Valley Hospital’s patient safety efforts, we employ Adventist Health’s system-wide approach to assessing and strengthening the culture of safety at our hospital. Part of this approach is our partnership with Duke University Health System staff member Bryan Sexton, Ph.D., on a groundbreaking quality initiative called the Culture of Teamwork and Safety Improvement Process. For this project, front-line staff at Simi Valley Hospital complete a survey to identify specific areas of concern, then Dr. Sexton reviews the survey results and offers insights and recommendations for how to address improvement.
The survey measures staff’s attitudes toward safety in seven areas: teamwork climate, safety climate, job satisfaction, stress recognition, working conditions, perception of hospital management, and perception of unit management.
Results: While six of these areas were deemed to be unsatisfactory in the 2008 survey, only three — stress recognition, working conditions and perception of hospital management — remained in that category in the 2009 survey, and all of those were within 10 percentage points of clearing the unsatisfactory range of scores.
The 2009 survey also revealed that the area of job satisfaction was particularly strong at Simi Valley Hospital. The hospital’s next culture of safety survey will be completed in February 2011.
EMERGENCY DEPARTMENT COLLABORATIVE
The goal of this project, in place at all Adventist Health hospitals, is to ensure superior quality in our Emergency Department (ED). Specifically, the effort focuses on:
- Patient flow (wait times, the length of time between arrival at the ED and being admitted, various patient care processes, and so forth),
- Patient satisfaction, and
- Quality of care related to the Centers for Medicare and Medicaid Services (CMS) core measures, including acute myocardial infarction and community-acquired pneumonia.
Results: From October 2009 — when we began to address patient flow in earnest — to November 2010, we experienced a significant drop in the average time patients have to spend in the Simi Valley Hospital Emergency Department. The change was particularly noticeable among patients who were stabilized in the Emergency Department then admitted to the main hospital. The chart below summarizes the drop in length of visit.
Oct 2009 Avg
Nov 2010 Avg
|3 hrs, 14 min
|2 hrs, 25 min
|49 min less (25%)
|6 hrs, 43 min
|5 hrs, 9 min
|1 hr, 34 min less (23%)
|3 hrs, 53 min
|3 hrs, 32 min
|21 min less (9%)
*Patient transfer time depends in large part on how much time it takes for the destination facility to respond.
PRESSURE ULCER CAMPAIGN
In conjunction with Adventist Health, Simi Valley Hospital is involved in an effort to reduce pressure ulcers — breakdown of the skin that occurs when a person remains in a stationary position for an extended amount of time. According to the Agency of Healthcare Research and Quality, the incidence of pressure ulcers among hospitalized patients increased steadily between 1993 and 2006.
The goal of Adventist Health’s Pressure Ulcer Campaign is to facilitate an interdisciplinary approach to avoiding pressure ulcers, efficiently managing care when they occur and identifying and implementing best practices to reduce the incidence of pressure ulcers.
Adventist Health has made significant progress toward identifying best practices to reduce hospital-acquired pressure ulcers. Simi Valley Hospital’s pressure ulcer prevention team meets regularly to review practice trends, new products and other measures that will reduce the incidence of pressure ulcers at the hospital.
Results: The rate of pressure ulcers at Simi Valley Hospital dropped throughout 2010, thanks in large part to education efforts with the hospital’s staff, as well as patients and their family members and other caretakers. By November 2010, the hospital-acquired pressure ulcer rate was 1.86%, which was below the Adventist Health goal of 2%. For 2011, the Adventist Health goal is 1.5%.
Simi Valley Hospital participates in an Adventist Health initiative to increase awareness among staff, physicians, patients and visitors regarding the importance of hand washing and the use of alcohol-based hand sanitizers to reduce the spread of disease.
Spearheading this effort are the “Germinators,” staff champions in departments throughout Simi Valley Hospital who help maintain compliance with the hospital’s hand hygiene protocols. In addition, the hospital has installed alcohol gel dispensers in key areas around the facility and has placed signage related to the topic in various areas of the hospital.
Patients and family members are encouraged to specifically request that physicians and other caregivers wash their hands in view of the patient or family. To facilitate this practice, the hospital provides conversation starters on the topic.
Results: Since the Germinator program began in 2009, there has been a dramatic increase in hand hygiene compliance at Simi Valley Hospital (see chart below). Compliance rates have reached above 90 percent for some months of 2010.
One of the ways Simi Valley Hospital sets a standard for clinical quality is by employing a set of best-practice indicators — proven actions that help to ensure a good outcome for patients — endorsed by the Centers for Medicare and Medicaid Services (CMS). Each of these actions is measureable, which provides a means to track success in applying the actions in the patient care setting. For instance, Simi Valley Hospital staff record the percentage of heart attack patients who receive an aspirin within a certain time frame.
Simi Valley Hospital focuses on four areas identified by the CMS: acute myocardial infarction (heart attack), heart failure, community-acquired pneumonia and the Surgical Care Improvement Project. Staff carefully measure the rate of implementation of these best practice indicators and compare them with the performances of other hospitals throughout the country in order to make improvements in care.
For purposes of measurement and goal-setting, the hospital combines the three main core measures of acute myocardial infarction, heart failure and pneumonia into a single composite score. In 2010, Simi Valley Hospital achieved an 89 percent implementation rate of the core measure indicators. The goal for 2011 is to increase that rate to 93 percent.
HCAHPS is an acronym for Hospital Consumer Assessment of Healthcare Providers and Systems. It is the first national, standardized, publicly reported survey that measures patient perceptions of acute hospital care.
The Centers for Medicare and Medicaid Services, which created the HCAHPS survey, has said that by publicizing the results, it hopes to provide consumers with information that might be helpful when choosing a hospital. Simi Valley Hospital voluntarily participates in HCAHPS as a complement to other quality improvement measurements.
To review the most current HCAHPS survey information, visit the Hospital Compare website. Our HCAHPS-related goal for 2011 is to increase the percentage of patients who say they would definitely recommend Simi Valley Hospital to a friend or family member to 72 percent.
Among the ways that Simi Valley Hospital and specific services have been recognized for achieving safety and quality standards are the following:
- The hospital received full, three-year accreditation from The Joint Commission, an independent, not-for-profit organization that is among the most prominent accrediting bodies in the health care industry.
- Adventist Health/Home Care Services of Simi Valley Hospital was, for the fifth consecutive year, named among the top 25 percent of home health programs in the nation by OCS, Inc., the nation’s leading provider of home care information.
- Simi Valley Hospital’s cancer program received a full three-year accreditation from the American College of Surgeons Commission on Cancer following a 2010 review of the program.
- The hospital’s Child Development Center is certified through the California Department of Education to provide outpatient therapy services for children in special education from infancy through high school.
- In addition, the Child Development Center has received numerous awards, including recognition from the Ventura County Down’s Syndrome Association, the Ventura County Autism Parents Group and the Special Education Advisory Committee for the Simi Valley Unified School District.
- The hospital received national recognition from the U.S. Department of Health and Human Services for its tissue and organ donor program when 75 percent of patients who were qualified donors became actual donors.
- The Simi Valley Chamber of Commerce named Simi Valley Hospital its 2008 business of the year.