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Hospital scores high on performance report

As a full-time employee at Pagosa Mountain Hospital (PMH), Bart Plumbley, RN, addressed the Upper San Juan Health Service District Board of Directors Tuesday night and offered a review of hospital staff achievements last year. Overall, his “Quality Performance Annual Report 2009” showed competent compliance in most areas.

Plumbley’s report provided useful insight into the workings of various hospital departments and employees, and how well each discharged their respective duties throughout 2009. The areas evaluated included nursing, infection control, medical records, laboratory and radiology services, human resources, plant operations and customer satisfaction.

In all of last year, hospital nurses saw 3,935 patients in the ER and tended to 138 who were admitted as either inpatients or swingbed patients. Of the 4,073 total, there were nine reported medication errors, with a compliance rate of 99.78 percent.

Patient incidents (including falls and injuries) totaled nine, for the same compliance rate of 99.78 percent. There were seven patient deaths, six of which were reported to Donor Alliance within 24 hours. Three actually donated organs or tissue.

Plumbley proudly announced that no hospital-acquired nosocomial infections were reported in 2009. Likewise, no catheter-associated infections or related urinary tract infections were reported, though regular monitoring continues. A few minor staff infections (MRSA) were reported, but are easily preventable with proper disinfection, hand-washing and the use of appropriate protective barriers (gloves, masks, etc.).

In 2009, out of 48 total hospital employees, four were injured in falls (slippery parking lots), one sustained injury while handling a defective door mechanism and four contracted illness through exposure.

However, all employees and volunteers received mandatory TB screening, while 92.2 percent received flu shots. With a 95-percent vaccination rate overall, 80 percent were inoculated against H1N1.

Proper documentation reduces medical records errors, but mistakes seem common in most hospitals. In the latter three quarters of 2009, PMH nursing documentation deficiencies among patient care records, consent forms and advance directives occurred 24.6 percent of the time. Of the 3,023 charts reviewed, 744 errors were found, equating to a compliance rate of 75.4 percent. The nursing staff has vowed to exceed 95 percent compliance in 2010.

Within those same 3,023 charts, which represent all ER patients, inpatients, observation patients and swingbed patients, physicians completed their responsibilities 88.9 percent of the time, resulting in 337 deficiencies.

The lab and radiology departments fared much better, with 99.8 percent and 99.66 percent compliance rates, respectively. In all, out of 34,468 lab tests(10,561 patients), just 59 unsatisfactory lab specimens were taken. Eight radiology errors — stemming from such things as incorrectly following ER orders — occurred among 3,190 tests performed on 2,331 patients.

Problems with the human resources department and plant operations were mostly minor logistical concerns and will largely be resolved through better documentation and ongoing evaluation.

Measuring customer satisfaction will largely depend on improving the response rate among customers polled. While the hospital goal is 95 percent patient satisfaction, just 25 percent of those served answered or returned inquiring PMH calls. However, patient satisfaction did exceed the goal in six of the nine months data were analyzed.

Based on Plumbley’s 2009 report, Pagosa Mountain Hospital departments are performing at or above the national average, while staff members have now set their sights on higher 2010 achievements. For a facility now entering its third year, PMH has certainly become a real community asset.