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St. James Hospital / Quality & Safety

Quality & Safety

What You Should Know About the Flu

St. James Hospital is committed to healing the body, mind and spirit. Our motto—"When Quality Matters"—underscores our commitment to providing the highest quality of care, service, patient safety, and patient/resident/client satisfaction. The objectives of the Strategic Quality Improvement Plan plan reflect St. James Hospital’s commitment to:

  • Promote and maintain a values-based organizational culture committed to caring through excellence that supports continuous quality improvement.
  • Enhance operational excellence including both clinical outcomes (quality) and perceptions of care (service).
  • Systematically identify and prioritize performance improvement opportunities.
  • Create a "just" environment that supports the identification and reporting of adverse events and/or near misses.
  • Apply external standards and/or references for benchmarking performance.
  • Utilize assessment activities as the basis for developing and implementing action plans responsive to findings.
  • Communicate results of performance improvement activities to and across all levels of the organization.

A key component of St. James Hospital’s quality commitment is the Patient Safety Program. This formal program allows staff to respond effectively to occurrences in the hospital, nursing home, physician offices or clinics, and proactively reduce the potential of medical errors. Our patient safety and quality activities are modeled after evidenced-based programs, meaning that our care practices are based on research and scientific studies to provide the best possible interventions and treatments.

One way patients and families can evaluate quality at St. James Hospital is through public "report cards" provided by the US Centers for Medicare and Medicaid Services Hospital Compare and Nursing Home Compare websites. They publish specific "indicators" of hospital and nursing home quality, and allow you to compare the results of other facilities. St. James Hospital uses these indicators—as well as many other types of quality data—to identify opportunities for improvement.

Quality and Patient Satisfaction Reports

Specific quality and patient satisfaction measures are regularly analyzed by the staff at St. James Hospital. You can select the links below to view a summary of our current performance

Sources of Quality Information

There are various external sources that can be valuable in assessing the quality of a health care organization. St. James Hospital uses all of these sources in monitoring its quality performance. Each source represents quality data in a way that is useful in measuring some aspect of our quality program:

Reports from these organizations are analyzed regularly and reported to appropriate staff members who have the greatest ability to act upon the data. In addition, St. James Hospital’s Board of Directors reviews the quality results from our hospital and nursing home, as well as recommended action plans and corrective measures.

Using Technology to Improve Patient Outcomes

Barcode Medication Verification1. BMV/Bedside Medication Verification (Bar Coding Medications)

In 2008, St. James Hospital invested in a high-tech system to improve patient safety. Called "Barcode Medication Verification"—or BMV—this system makes sure our patients get the right medicine, at the right time, in the right dosage.

How it works is when patients get admitted through our registration area or emergency department, they receive a bracelet imprinted with a unique barcode. The physician then orders any needed medications, and the orders go electronically to our pharmacy. The pharmacist fills the orders, and double checks for any allergies. Each medication has its own unique barcode, specific to that medicine and strength.

Medications are taken out of automated dispensing machines located on the nursing units, and placed in drawers on the BMV workstation carts. The nurse or respiratory therapist wheels the BMV cart to the patient at bedside, scans the bracelet, and scans each medication to be sure the patient gets the right medicine, at the right time, in the right dosage. If anything doesn’t match—patient name, medication name, dose or time—an alert will immediately come up on the screen so that corrections can be made before the medication is given to the patient.

This technology and its procedures ultimately reduce the potential for medication errors. This is a serious problem across the country, accounting for an estimated 400,000 errors every year in the US. Confusing packaging and labeling as well as look–alike or sound–alike drug names significantly contribute to medication errors. Also, medications often are dispensed in less-than-ideal situations, such as at night in dimly lit patient rooms or in critical situations requiring rapid response.

BMV offers many advantages to patient care, by allowing our clinical staff to:

  • Validate the path of patient to medication to dosage through barcode scanning
  • Immediately view critical patient information such as allergies, latest test results, and vital signs
  • Enter and view comments about dosage, schedule, administration, and clinical indicators
  • Display current medications and history

St. James is proud to have been the first—and still the only—hospital in the region to have Barcode Medication Verification integrated into its inpatient care areas.

2. Computerized Physician Order Entry (CPOE)

In 2002, St. James Hospital began the process of implementing computerized physician order entry (CPOE) to improve patient safety and care delivery.

CPOE is software that physicians use to enter their clinical orders directly into the computer. The software allows for checking for drug interactions, allergies, duplicate orders, and dosage at the point of order, before care is administered. The physicians get immediate feedback on potential risks, and unlike paper orders, computerized orders are always legible. Other advantages of CPOE:

  • Elimination of transcription errors
  • Elimination of errors due to poor handwriting
  • Elimination of errors resulting from allergies and duplicate drugs
  • Reduced time to fulfill physician orders

Although CPOE is a proven method to decrease medication-related errors and adverse events in hospital patients, to–date only a handful hospitals across the US have installed the system. St. James Hospital served as a CPOE pilot site.

3. Rochester Regional Health Information Organization (RHIO)

In 2010, St. James Hospital began participating as a provider of electronic information to the Rochester Regional Health Information Organization (RHIO). RHIO is a secure health information exchange system that gives authorized medical providers access to essential patient information such as lab results and radiology reports. This is one of several major steps St. James has taken to enhance timely access to data and improve quality of care.

The RHIO helps improve the quality of care. People often visit many different offices and physicians when getting help with a medical condition. With a RHIO, your information goes where you go. That helps your doctors make more informed decisions about your care with accurate, up–to–date information.

When health information is shared through a RHIO, patients can also avoid repeated testing, get second opinions more easily, and minimize errors caused by hard-to-read handwriting and transcriptions. It also is extremely helpful in the event of a health emergency.

Patients must provide consent for their providers to view information electronically through the RHIO. Your information is only shared with your doctor if you sign a consent form. The RHIO has many built-in features that make it highly secure. Patient information is protected at the hospital or doctor’s office, and is only accessible by authorized users. Keep in mind that most people’s health information is already being shared with other providers via phone, fax or paper as part of the normal course of care.

The state and federal government are promoting the creation of RHIOs to move toward national standards for secure electronic exchange of health information. Eventually all hospitals and physicians who participate in Medicare and Medicaid will be required to join. Visit or call 1-877-865-RHIO (7446) for more information.