Quality & Safety

At ECM Hospital, we are committed to balancing clinical excellence with safe, high-quality, compassionate care for our patients.  We set aggressive quality standards, striving to exceed state and national benchmarks in the areas of clinical quality, patient safety and customer service. As we set the bar high and raise it again and again, we are regularly recognized for our commitment to quality and safety, exceptional advanced care and leading outcomes. Physicians, nurses and staff are focused on continually improving patient safety and the quality of care by adopting best practices, confirmed by research to improve patient outcomes. NAMC is accredited by The Joint Commission, an independent not-for-profit organization that evaluates and accredits health care organizations and programs.

The Quality & Patient Safety is made up of the following departments:
•Patient Safety
•Regulatory Compliance – Accreditation
•Risk Management
•Infection Control
•Performance Improvement
•Clinical Registries and Designations

What is Quality Healthcare?

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” (Institute of Medicine)

Six Aims for Improvement

In response to these challenges, the Institute of Medicine has established six aims for improvement. Health care should be:

  1. Safe: avoiding injuries to patients from the care that is intended to help them.
  2. Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse).
  3. Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patients’ values guide all clinical decisions.
  4. Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
  5. Efficient: avoiding waste, including waste of equipment, supplies, ideas and energy.
  6. Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status.

(Excerpt: Crossing The Quality Chasm, A New Health System for the 21st Century, Institute of Medicine, 2001, National Academy of Sciences.)

What is Patient Safety?

Patient Safety has been defined as a patient’s “freedom from accidental injury when interacting in any way with the healthcare system.”

National Patient Safety Goals

The National Patient Safety Goals (NPSGs) are annual goals established by the Joint Commission (JC) and are designed to encourage hospitals to make improvements in the way they care for patients, to reduce preventable medical errors, and to improve patient safety.

The purpose of these goals is to promote specific improvements in patient safety. The NPSGs highlight problematic areas in healthcare, using both evidence and expert based data, which are updated annually. These goals are designed to require health care organizations to protect patients from the negative impact of specific health care errors.

The NPSGs focus on a variety of safety challenges that most hospitals face on a daily basis. Each year, health care providers must meet the requirements of the Joint Commission’s NPSGs as part of the accreditation process. Hospitals must do more than simply perform specified tasks to achieve compliance with these goals. To assure safe health care environments, hospitals must continually analyze fundamental workflow systems and redesign those systems as needed.

Because safe, high quality healthcare can only be provided in a system that has been designed to support such care, the NPSGs focus on system-wide solutions wherever possible. Institutions are surveyed by the JC for compliance with these goals. Each year health care providers must meet the requirements of the JC NPSGs as part of the accreditation process. HCA is committed to meeting these goals not only to meet compliance requirements for JC but also because it is the right thing to do for our patients.

To learn more about the National Patient Safety Goals, obtain a status report on how our facility is accomplishing these goals and how we compare to other Joint Commission accredited organizations nationwide and statewide, visit the Hospitals Joint Commission Accreditation Quality Report website.

Why Are We Publishing Quality Data?

You can’t improve what you don’t measure. That is why we have committed to measuring and publicly reporting our performance. In these quality reports we show our patient satisfaction scores and performance on nationally recognized quality indicators and practices. These measures will help you assess our clinical quality on specific procedures and conditions as compared to established national standards and other hospitals. We are proud of what we have accomplished and we want to share these results with you. These results are updated quarterly and can be found on the Hospital Compare website.

What Are Our Quality Reporting Measures?

Sepsis, Stroke, Heart Attack (also called Acute Myocardial Infarction-AMI), Heart Failure, Pneumonia, Surgical Care, Infection Prevention (measures like Central-line associated blood stream infection-CLABSI, Catheter associated urinary tract infection-CAUTI) and Patient Safety (measures like Falls, Pressure ulcers). These conditions are common reasons for patients to go to the hospital and affect hundreds of thousands of patients each year.

 Why Are These Quality Measures (also known as National Quality Improvement Goals) Important?

  • Achievement of these goals is evaluated against standardized performance measures that hospitals are expected to follow for improving patient care and outcomes.
  • Healthcare providers recognize these as “desirable goals” for treating patients with the identified conditions.
  • Patients who receive care based on certain desirable practices are more likely to improve or avoid other medical problems.

Accreditations, Awards and Recognitions

  1. The Joint Commission accredited NAMC recently in 2016
  2. The Joint Commission accredited Lab Services in 2015
  3. Certified as a Chest Pain Center by Society of Cardiovascular Patient Care
  4. Certified as a Primary Stroke Center by The Joint Commission and American Stroke Association
  5. First Hospital to be certified on Advanced Palliative Care and continued to be the only hospital in Alabama since 2012
  6. Outpatient CT services received ACR accreditation
  7. The Tri-State Center for Breast Health received ACR accreditation for Mammography Services
  8.  NAMC Cardiac Surgery Program has received a 2 star rating for quality and clinical excellence of heart surgery by the Society of Thoracic Surgeons (STS)
  9. NAMC received American Heart Gold Stroke “Get with the Guidelines” designation at the 2016 International Stroke Conference
  10. Blue Cross Blue Shield’s Blue Distinction recognition for Maternity Care
  11. The Joint Commission’s Top Performer on Key Quality Measures (AMI, HF, PN, SCIP) in 2015, 2014 and 2013
  12. Multi-year recognition by the American Heart Association and American Stroke Association for implementation of the Get with the Guidelines program in the treatment of Stroke and Heart Attack patients
  13. The Tri-State Center for Breast Health is a certified participant in Nation Quality Measures for Breast Centers (NQMBC)