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Top Performer on Key Quality Measures®

Community Hospital was named Top Performer on Key Quality Measures®” on October 31, 2013, by The Joint Commission, the leading accreditor of health care organizations in America. Community Hospital was recognized for its achievement on the measure set of Surgical Care.

Community Hospital was recognized by The Joint Commission for exemplary performance in using evidence-based clinical processes that are shown to improve care for certain conditions. The hospital is one of 1,099 hospitals in the U.S. earning the distinction of Top Performer on key Quality Measure for attaining and sustaining excellence in accountability measure performance. The ratings are based on an aggregation of accountability measure data reported to The Joint Commission during the 2012 calendar year. The list of Top Performer organizations represents 33 percent of all joint Commission-accredited hospitals reporting accountability measure performance data for 2012.

Community Hospital and each of the hospitals that were recognized must:

1. achieve cumulative performance of 95 percent or above across all reported accountability measures;

2. achieve performance of 95 percent or above on each and every reported accountability measure where there are at least 30 denominator cases; and

3. have at least one core measure set that has a composite rate of 95 percent or above, and within that measure set all applicable individual accountability measures have a performance rate of 95 percent or above.

A 95 percent score means a hospital provided an evidence-based practice 95 times out of 100 opportunities. Each accountability measure represents an evidence-based practice. Examples of an evidence-based practice in Surgical Care include:

• Antibiotic received within one hour prior to surgical incision

• Antibiotic selection

• Antibiotics stop within 24 hours of surgery end time

• Appropriate hair removal

• Urinary catheter out by post op day one or two

• Temperature management in the operating room

• Beta Blocker therapy management

• Patients who receive appropriate VTE prophylaxis

Studies show patients will have fewer post op infections and better recovery time by implementing and achieving success in following these surgery related processes. In fact, Community Hospital had only a .04% post-op surgery site infection rate from January 1 to September 1, 2013. That's only four infections in every 10,000 procedures.

“We are very honored to received this recognition,” said Jim Ulrich, Community Hospital President & CEO. “It represents the dedicated effort of our entire team.

“We also understand that what matters most to patients at Community Hospital is safe, effective care. That’s why we have made a commitment to accreditation and to positive patient outcomes through evidence-based care processes,” he added.

In 2008, Community Hospital adopted process-based management as its system to develop and improve processes, leading to quality improvements. Management of the processes helps the hospital focus on whether they are meeting and exceeding the customer’s expectations and ask what is the “voice of the customer.”

The surgeons at Community Hospital whose care contributed to this award include: Walter Eskildsen, M.D., General Surgeon; Terrance Foote, M.D., Ob/Gyn; Scott Franssen, M.D., Orthopedic Surgeon; Brenda Kopriva, M.D., General Surgeon; Todd Pankratz, M.D., Ob/Gyn; and Michael McCarty, M.D., Orthopedic Surgeon.

About Community Hospital