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In 2001, St Joseph Hospital in Augusta, Ga, reorganized its patient safety initiatives to improve patient care outcomes. By 2004, we decided to focus the many clinical projects toward one goal, reducing inpatient mortality. One year later, raw mortality decreased by 29% and severity-adjusted mortality decreased by 25.5%.

In 2001 through 2003, our agency received deficiencies in infection-control practices, specific to wound care, from JCAHO and Medicare surveyors. Efforts to correct this pattern were initially unsuccessful. As a result, in 2003, an interdisciplinary performance improvement team was formed to assess, plan, and implement a wound care program utilizing research-based best practice. The changes in process, practice, and education resulted in success, with improvement evidenced by 100% acceptable practice during our 2004 unannounced JCAHO/Medicare survey, a declined rate of wound infection per our Medicare OASIS Adverse Event Report, and a decrease in wound care patient visits.

In general, the unannounced JCAHO survey is a more positive and patient-focused process than surveys in the past. Staff are able to demonstrate and explain what they actually do in their job on a day-to-day basis rather than stating policies. In the continuous survey-readiness process, there is less emphasis on document preparation and more on effective care. The process is appropriately clinically focused.

Nosocomial pneumonia is the second most costly infection occurring in US hospitals. It is associated with high mortality and morbidity and is considered one of the most difficult infections to diagnose and prevent. In 1999, St Joseph Hospital formed a multidisciplinary Ventilator-Associated Pneumonia Performance Improvement Team to tackle the myriad of issues involved in the prevention of ventilator-associated pneumonia and the care of this high-risk patient population. The accomplishments of the team were significant, with a 95% reduction in ventilator-associated pneumonia.