Quality and Safety

OWNER: Chief Quality Officer Joshua Griggs, MD PRIORITY: We will be a high reliability organization dedicated to zero events of preventable harm for our patients and team members.

KPM #1 - ZERO PATIENT

HARM: On our journey to become a high reliability organization, our goal is to increase the quality of care we provide for all of our patients. To measure our success, we have created a Zero Harm composite which includes the following: • C. diff: Hospital-acquired infection of the large intestine caused by the bacteria Clostridium Difficile. • Severe Hypoglycemia: Hospital patients who have severe low blood sugars. • Falls: Department of Health reportable, unplanned descent to the floor with or without injury. • CLABSIs: Hospital-acquired Central

Line-associated Blood Stream

Infections. • CAUTIs: Hospital-acquired Catheterassociated Urinary Tract Infections. • Opioid Reversal: Toxicity due to excessive opioids administered by the hospital. • Post-op DVTs: Deep Vein Thrombosis (blood clot) following a surgical procedure. • HAPIs: Department of Health reportable Hospital-Associated

Pressure Injuries (bed sores) that occur when patients have limited mobility. As we reduce the incident rates of these events, we move closer to our ultimate goal of doing no harm.

KPM #2 - TEAM MEMBER SAFETY - TOTAL CASE INCIDENT RATE (TCIR):

In addition to our commitment to patient safety, equally important is the safety of our team members. With a focus on preventing employee harm, we will reduce our Total Case Incident Rate (TCIR) which is a ratio of all OSHAreportable safety events in relation to total employee worked hours. Using this standard measure (TCIR) allows us to compare ourselves to a national benchmark. SUPPORTING METRIC - LENGTH OF STAY: We improve

quality of care when we appropriately match the care setting to the patient’s needs. We care that a patient’s stay in the hospital is for the appropriate amount of time based on their clinical condition. In addition, research shows that the longer a patient remains in the hospital, the greater likelihood they will incur Hospital-Acquired Infections (HAIs) and other incidents of harm. To optimize care delivery and improve outcomes, we will focus on improving our patient length of stay as a supporting metric.

NEW GENERAL SURGEON: Jimmy Barger, DO, FACOS, joined the team of General Surgeons at Skagit Regional Health in 2020 and practices at Cascade Valley Hospital.