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Quality report: sepsis bundle compliance improves to 72.7%; one C. difficile reported for April; board approves quality report and credentialing slate
Summary
The hospital reported improvements on severe sepsis bundle compliance and reductions in several hospital-acquired infections, but noted one delayed-reported C. difficile case in April. The board approved the quality report and credentialing recommendations.
The Hospital Authority board approved the quality report and a medical staff credentials slate after hearing a detailed update on safety, infection control and patient satisfaction metrics.
Felicia Denson, director of quality and patient safety, presented the May/April dashboard and said the hospital validated reporting and resumed tracking several metrics. She reported that the hospital ended May with no falls with injury and had achieved Leapfrog hand-hygiene observation targets for 18 consecutive months. Barcode medication administration compliance for May reached 97%, above the 95% goal. Denson said the hospital had gone more than 365 days without CLABSI (central-line associated bloodstream infection), CAUTI (catheter-associated urinary tract infection), MRSA bacteremia or surgical site infection events.
Denson also reported one C. difficile infection that occurred in April and was reported late because of reporting-system issues. "This C. diff event took place in April ... we had gone about 615 days without a C. diff event," Denson said, adding that staff performed a deep dive with nursing, pharmacy, laboratory and environmental services to adjust testing, documentation and antimicrobial stewardship practices.
Under timely and effective care metrics, the severe sepsis bundle compliance rose to 72.7% for April, above the 58% national benchmark cited by the presenter. Denson said the improvement followed multidisciplinary work on blood culture timing and IV fluid administration, including coordination with emergency department staff.
On obstetrics, the hospital missed its C-section rate target for April—27.3% versus a 24.7% goal—but the rate declined from March, and staff are reviewing records to ensure indications and coding align with metric exclusions.
On patient experience, inpatient survey response rates rose modestly from 17 to 21 returned surveys between April and May, and the hospital met goals for three of four inpatient satisfaction questions (responsiveness, cleanliness and quietness) while willingness to recommend fell to 57.1%. Denson said the hospital will expand patient satisfaction reporting in August to include emergency department, ambulatory surgery and clinics.
Doctor Miller presented the credentialing report and recommended the initial appointments of three physicians: Dr. Bricknell (general medicine/internal medicine and cardiology), Dr. Johnson (general surgery with bariatric experience) and Dr. Stone (internal medicine and neurology). He noted resignations by Dr. Humes (emergency medicine) and Dr. Drummond (psychiatry). The credentialing slate was moved and seconded and was approved by the board.
After the quality presentation, the board moved to approve the quality report. A motion to accept the report passed.
Ending: Board members congratulated staff for sustained infection-control performance, noted work to address the C. difficile event and directed continued review of obstetrics coding and patient experience improvement plans.
