Patient care statistics have improved at Winneshiek Medical Center.

At last week's meeting of the WMC Board of Supervisors, Interim Chief Medical Officer Dr. Steven Davis explained to the Board a number of health outcome improvements from fiscal year 2012 to 2013.

Areas of improvement included door-to-EKG time for chest pain. In 2012, patients waited an average of 12.4 minutes to have an electrocardiogram. WMC was able to cut that time in half, with an average of just 6 minutes in 2013.

WMC also reduced its troponin draw-to-report time from 79 minutes to 52 minutes. The troponin test measures the levels of certain proteins in the blood.

In addition, patient falls decreased from 1.55 per 1,000 patient days to .9 falls, and medication errors declined from 4.59 per 10,000 medication doses to 4.02.

WMC also excelled in carrying out non-clinic Universal Protocol, increasing from 94 percent to 100 percent. Universal Protocol was created to prevent wrong-person, wrong-procedure, wrong-site surgery in hospital and outpatient settings. The Universal Protocol consists of three steps, including a pre-operative/pre-procedure verification process, marking the operative/procedure site and a final verification, which is performed immediately before starting an operation or procedure.

While WMC's diabetes measures declined from 44 percent to 42 percent, they still met goal.

Davis explained there were several areas, which modestly declined between fiscal year 2012 and 2013 and are under WMC's goals.

These include the inpatient surgical care improvement program (a national quality initiative to ensure patient safety during a surgical procedure), which fell slightly from 98 percent to 97 percent, the acute myocardial infarction bundle (emergency procedures for heart attack) went from 100 percent to 94 percent, the readmission rate rose slightly from 7 percent to 7.2 percent and the ambulatory (outpatient) surgery surgical care improvement program fell slightly from 95 percent to 94 percent.

"Like many measures in health care, quality rates go up and down every quarter. We find it useful to monitor the trends that occur over time. Dramatic changes or trends over time alert us to areas to work on or successful improvement process. We are pleased to see only minor variations to our quality measures, with many areas showing improvements from last fiscal year," Davis explained after the meeting.

"If the mix of patients with pneumonia was higher this quarter, that alone can make the readmission rate higher."

Davis noted a report on 30-day readmission rates by diagnosis.

"For pneumonia and congestive heart failure, national readmission rates were 15.7 percent and 24.7 percent, respectively," said Davis.



JCAHO survey

In a related matter, Chief Nursing Officer Linda Klimesh said the hospital is expecting a visit from the Joint Commission on Accreditation of Healthcare any day.

"We are expecting them sometime in the next three weeks and we have someone watching the website," said Klimesh.

Klimesh said the Medical Center will have half an hour's notice the JCAHO team is coming to spend three days assessing the Medical Center's practices.

The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 20,000 healthcare organizations and programs in the United States. In many states, Joint Commission accreditation as a condition of licensure and the receipt of Medicaid reimbursement.

Inspections typically follow a triennial cycle, with findings made available to the public in an accreditation quality report on the Quality Check Web site.