Quality & Safety

Quality Improvement

Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.  Santa Clara Valley Medical Center is committed to the delivery of high quality clinical care and services delivered in an environment that promotes safety.  Strategies to ensure that quality is achieved include assessment and analysis, process redesign, and education.

Accreditation, Regulatory & Licensing

Accreditation, Regulation, and Licensing  (A,R&L) provides enhanced organizational attention on compliance, survey readiness, and regulatory and licensing requirements, and contribute to successful survey outcomes.  A,R &L also assesses continuous compliance with regulatory and legal requirements and standards set by accrediting agencies through internal evaluation of clinical services and operations, analysis of data, auditing and direct observation, and survey by external agencies either as a part of regular licensing and accreditation activities or in response to specific issues.

Risk Management

The Risk Management Department is responsible for receiving, reviewing, following up on corrective actions, and monitoring all unusual occurrence reports at Santa Clara Valley Medical Center (SCVMC) which includes inpatient and ambulatory settings.  Risk Management’s primary focus is to ensure that patients are getting quality care and are safe.  Errors happen in healthcare settings and with the recognition of events, there is opportunity for improvement. Risk management assures that SCVMC is in compliance with current regulations and The Joint Commission standards as it relates to risk reduction, mitigation of events, and patient safety. The department provides information, education, and trends along with the actions that are implemented to reduce medical errors and trends in the organization.  Risk Management staff collaborates with providers, employees, and County Counsel as needed regarding occurrences.

Infection Prevention

The infection prevention department at SCVMC is a branch of the quality and safety program of the facility. The department, in collaboration with the epidemiology medical staff is responsible for ensuring the safety and wellbeing of the all individuals who either work at the facility, is in training at the facility or is a visitor to the facility; by limiting the risk of exposure to blood borne pathogens, multidrug resistant organisms and communicable diseases. The department is engaged in a dynamic surveillance program to identify process and outcomes measure that are not in compliance with the infection control policy manual.

Environment Health & Safety

Santa Clara Valley Medical Center’s Environmental health and Safety Service program evaluates and audits the environmental health and safety risks of various departments within the Santa Clara Valley Health and Hospital System. This includes conducting health and safety inspections, ensuring that hazardous materials and waste are handled properly, maintaining environmental permits and updating VMC’s Hazardous Materials Business Plan and Hazardous Communications program.

Outcome Measures	CLABSI	Colon SSI	NTSV	Sepsis Mortality	VTE
Santa Clara Valley Medical Center	0.79	2.32	22.80	9.36	0.00
California Level	0.79	0.98	23.50	14.30	3.00
National Level	0.77	0.90	25.90	25.00	3.00
Measure Period	10/01/2017-09/30/2018	10/01/2017-09/30/2018	01/01/2018-12/31/2018	01/01/2018-12/31/2018	10/01/2017-09/30/2018

Program Status
YES	This hospital has a Maternity Safety Program in place. A maternity safety program provides a coordination approach and emergency response to risks associated with pregnancy and childbirth.
YES	This hospital has a Sepsis Protocol in place. A sepsis protocol provides guidance for a coordinated approach to identification and treatment of an infection and inflammatory response which is present throughout the body.
YES	This hospital has a Respiratory Monitoring program in place. Respiratory Monitoring provides guidance for assessment of risk of respiratory depression and includes continuous monitoring of breathing and functioning of the lungs and circulatory system when indicated.

Outcome Measure definitions:
CLABSI – Central line-Associated Blood Stream Infection: A serious infection that occurs when germs enter the bloodstream through a central line. A central line is a special intravenous catheter (IV) that allows access to a major vein close to the heart and can stay in place for weeks or months. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitation: In the calculation of the Standardized Infection Ratio (SIR) the CDC adjusts for differences between hospitals. However, patient risk factors are not taken into account. These patient -specific variables (e.g., poor skin integrity, immunosuppression) can increase the risk of developing a central line infection. Hence, the SIR for hospitals that care for more medically complex or immunosuppressed patients may not be adequately adjusted to account for those patient-specific risk factors.
Colon SSI – Colon Surgical Site Infection: An infection (usually bacteria09 that occurs after a person has colorectal surgery that occurs at the body site where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, organs, or implanted material. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicated that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitation: Some, but not all patient-specific risk factors are included (e.g., trauma, emergency procedures) Hence, the SIRs for hospitals performing more complex procedures or with larger volumes of trauma or emergency procedures may not be adequately adjusted to account for those patient-specific risk factors.
NTSV – Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate: The percentage of cesarean (surgical) births among first-time mothers who are least 37 weeks pregnant with one baby in a head down position (not breech or transverse). Lower values indicate that fewer cesareans were performed in the hospital among primarily low risk, first-time mothers. Limitation: NTSV rates do not take into account certain obstetric conditions, such as placenta previa, that may make Cesarean delivery the safer route for both mother and infant.
Sepsis Mortality: Percent of patients, with a severe infection, who die in the hospital. Most sepsis cases (over 90%) start outside the hospital. Lower percentage of death indicates better survival. Limitation: use of discharge/ administrative data is limiting since such data has lower specificity for diagnoses than clinical data. In addition, without risk adjustment for differences in patient-specific factors, comparing rates among hospitals in difficult.
VTE – Venous thromboembolism: The measure of patients who develop deep vein clots who had not received potentially preventative treatment. Limitation: Although not adjusted to account for patient-specific risk factors, this rate in helpful in distinguishing a hospital’s adherence to the practice of administration VTE prophylaxis to all appropriate patients.