Click on each link below for a complete explanation.
Community Service Plan
Quality encompasses a number of things: Safety, patient care, patient experience while at ECH, employee satisfaction, hospital funding, insurance reimbursement... the list goes on.
ECH has undertaken a number of quality initiatives to better serve its patients. Quality care benefits the patient, while ensuring that the hospital can continue to receive important funding - payment from Medicaid and Medicare, government-sponsored grants, as well as ongoing community support.
There are a number of Department of Health initiatives, along with national patient safety goals that ECH strives to meet or exceed. Quality is everyone's job at ECH. The Quality Improvement Committee (board of directors) provides strategic direction about various initiatives, the quality department spearheads initiatives and everyone in the building is responsible for implementing the programs that relate to quality. From the board chair to nursing to housekeeping staff... everyone is responsible.
What is a critical access hospital?
Elizabethtown Community Hospital is the only critical access hospital in Essex County accredited by the Joint Commission. This designation is given to small, rural hospitals that are located over 35 miles from another hospital. They are required to provide initial, life-saving care so that the patient can survive the ambulance or helicopter trip for specialized care. Critical access hospitals must have agreements with other facilities that are willing to accept patients needing additional care. Those hospitals must trust the abilities and capabilities of the CAH, in terms of managing initial assessment and care of the patient. There are 1,325 CAHs across the United States; 13 of those are in New York state.
JOINT COMMISSION ACCREDITATION & NOTICE REGARDING SAFETY &
QUALITY OF CARE
The Joint Commission conducts periodic accreditation surveys of Elizabethtown Community Hospital. These surveys evaluate compliance with nationally established Joint Commission standards. Results determine whether accreditation should be continually awarded to Elizabethtown Community Hospital.
The Joint Commission standards deal with safety quality-of-care issues, including the safety of the environment in which care is provided.
Review the results of the hospital's most recent Joint Commission Survey at healthcarequalitydata.org.
As a patient, family member, community representative or employee of Elizabethtown Community Hospital you have the right to notify the Joint Commission regarding any concern about the quality of care provided, safety of care provided, or safety of the environment in which care is provided. Anyone believing that he or she has pertinent and valid information about such matters should notify the Joint Commission.
You may contact the Joint Commission offices toll-free at 800.994.6610 or by email at firstname.lastname@example.org.
"Quiet for Patients" campaign (SHHH)
Elizabethtown Community Hospital is dedicated to improving patient and staff experience by striving to decrease noise in the hospital environment.
A "Quiet for Patients" campaign committee was formed to implement noise reduction strategies. Some strategies that have begun:
Shhhhh! Posters throughout the hospital building featuring staff pictures.
Patients receive flyers/cards upon admission to let them know about noises they can expect to hear - things that ECH has little control over; they are given and a pair of ear plugs upon arrival.
A dedicated phone line was created (SHHH) 7444 so patients can call if it's too noisy.
Patient rooms have posters reminding patients to speak up if the environment is too noisy.
Noise monitors will be researched for the inpatient area.
Staff members will remind their co-workers and visitors if voice levels are too high.
The door to the cafeteria will be shut at all times.
ECH asks that staff with "noisy" shoes be considerate of the disruption this can cause and wear shoes that support a quiet environment.
The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. HCAHPS (pronounced "H-caps") is a 27-item survey for measuring patients' perceptions of their hospital experience.
The standardized survey produces data that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of HCAHPS results creates new incentives for hospitals to improve quality of care. Third, public reporting enhances accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment.
One thing to bear in mind is that, when viewing HCAHPS data, consumers must ensure that they are comparing similar hospitals. For example, ECH has a small number of people that use the inpatient unit each year... and only a fraction of those complete the survey. It's best to try to compare ECH to other critical access hospitals (rather than against Fletcher Allen Health Center or other larger facilities) so that an accurate comparison can be made.
Critical access hospitals like ECH are not yet required to report data. ECH began doing so in 2011.
The rates displayed are ECH data reported from January 2012 - November 2012. Timing of this information is based on release of information from Press Ganey.
The national average is based on all hospitals that use Press Ganey to conduct patient satisfaction (HCAHPS) surveys.
ECH achieves significant increase in Emergency Department patient satisfaction scores
Patients who visit ECH or one of its community-based health centers are sent a survey upon discharge by Press Ganey (the organization that conducts ECH surveys). These surveys measure patient perception. ECH is scored from 0-100 - patients choose one of four responses (Very Poor = 0; Very Good = 100).
The chart represents ECH data reported from January 2012 - November 2012. Timing of this information is based on release of information from Press Ganey.
Patient Satisfactions (Departmental)
The national average is based on all hospitals that use Press Ganey to conduct patient satisfaction surveys.
Hand hygiene is a simple thing and it's the best way to prevent infection and illness. There are two ways to clean hands. Using an alcohol based hand rub, which kills organisms in seconds or, when hands are visibly soiled, using soap and running water.
Hand hygiene is an important practice for health care providers and has a significant impact on reducing the spread of infections in hospitals. Hand hygiene is a different way of thinking about safety and patient care and involves everyone in the hospital, including patients and health care providers.
At ECH, our infection control nurse and staff educator performs hand washing checks on a random basis to help ensure compliance. The hospital staff wears appropriate gowns and gloves when working with some patients. Alcohol-based hand sanitizers are located throughout the facility so that staff and visitors are able to quickly eliminate germs from their hands before and after meeting with patients.
Bedside Medication Verification
Giving medication is serious business. A ECH, caregivers strive to ensure that medication errors do not occur. The hospital began using a bedside medication verification system in 2010.
Patient and the medication data are present in the wrist band of the patients, medicine labels and the nurses ID. These codes (barcodes/RFID) allows for confirmation of the identification of patient, medication, dose, time and route of administration. Before administering a medication or a blood product, the caregivers or the nurse administering the medicine scan these barcodes to verify the details of the medicine and the patient. Using this it is possible to alert them in case of any discrepancies in dose, identity of patients, route, and medication or if the dose of medication is not due. Additionally, other data such as the batch number, expiry dates, etc., can also be obtained from the barcodes.
Employees that are satisfied with their jobs are happy, productive and engaged - engaged with patients, co-workers, and with continually working to make ECH a better facility.
Community Service Plan
A Community Service Plan is a document prepared by the hospital. It is an annual requirement of the New York State Department of Health that provides information about the hospital's outreach programs, services, and activities.
- 2012 Update
- 2009 Plan
- 2007 Plan