The first question we ask ourselves is, “What are the quality measures that we need to follow?” After we know the requirements, we can figure out how we can meet these quality measures. These requirements are given to us by entities such as the State of California, The Department of Public Health, Joint Commission, and many others. These different entities have criteria and either you meet them or you don’t. We can only be accredited if we meet these standards.
Our Quality Initiative Coordinator looks on a daily basis at all of the patients in the hospital and makes sure we are following the best research-based patient care protocols such as: giving the antibiotics to the patients within one hour of surgical cut time, or prescribing the correct medications for discharge for certain conditions. We have someone who is looking at every patient, every day, and giving feedback to the physicians and staff.
We also do a lot of educating nurses and staff because they are very busy attending to patients and other needs of the hospital. Because we know the latest and most up-to-date requirements, we need to educate care givers about the right care to the patients and ensure everything is documented properly in the patient record.