Quality & Safety

We encourage you to review our hospital’s score on Hospital Compare in comparison to other area hospitals. Hospital Compare is determined by Medicare/Medicaid/CMS. Additional public quality, care and safety scores can be found with The Leapfrog Group and The Joint Commission.

Quality and safety matter to us, because you matter to us.

Our awards, accolades, rewards, recognitions and designations awarded to us by outside organizations demonstrate our commitment to providing excellent healthcare while maintaining best practices for quality and safety. Some of our most recent and notable recognitions include:

  • “A” Hospital Safety Grade from The Leapfrog Group
    • We have received “Straight A’s” since 2013; that’s 11 consecutive times!
  • Gold Seal of Approval for Chest Pain Certification by The Joint Commission
  • Advanced Certification for Primary Stroke Centers by The Joint Commission
  • Blue Distinction Center+ for Knee and Hip Replacement by Blue Cross Blue Shield
  • Blue Distinction Center+ for Maternity Care by Blue Cross Blue Shield
  • 2017 BEST for Babies Hospital Designation by Tennessee Department of Health and Tennessee Hospital Association (THA)
  • Top Performer on Key Quality Measures for five consecutive years by The Joint Commission
  • Mission Lifeline NSTEMI Award by American Heart Association
  • 2016 Performance Leadership Award by iVantage Health Analytics and the National Organization of State Office of Rural Health (NOSORH)
  • Exemplar Hospital by Institute for Healthcare Improvement

Putting Quality and Safety First

To maintain best practices and care for our patients, NorthCrest participates in several quality and safety processes. These processes and initiatives ensure that you are receiving the best care while within our facility. Healthcare is constantly evolving, as are patient needs; we change and implement new practices to ensure patient safety and quality care.

NorthCrest utilizes the Comprehensive Unit-based Safety Program (CUSP) Teams model for performance improvement initiatives.

  • Tennessee Hospital Association/Tennessee Center for Patient Safety
  • Purpose: Improve or reinforce good cross-disciplinary communication and teamwork, enhance the coordination of care, address overall patient safety and works toward healthy unit culture.

To learn more about our specific initiatives and the CUSP Teams at NorthCrest Medical Center, read more below:

BEST for BABIES

The BEST award stands for breastfeeding, early elective delivery reduction and safe sleep for Tennessee babies. Hospitals must meet the following criteria to receive the award:

  • Breastfeeding – an increase of five percent in newborn breastfeeding initiation rates from 2015 to 2016, or a minimum breastfeeding initiation rate of 90 percent in 2016
  • Early elective delivery – hospitals should have early elective delivery rates at or lower than five percent for 2016
  • Safe sleep – hospitals must have received Cribs for Kids® national safe sleep certification at a minimum of bronze level, submitted the TDH annual safe sleep hospital policy report for 2016 and demonstrate a minimum of 90 percent of cribs as safe in crib audits in the 2016 report

Early Elective Deliveries

  • Tennessee Center for Patient Safety/Tennessee Department of Health
  • Maintain 0 elective deliveries <39 weeks.

Cribs for Kids 

  • Tennessee Center for Patient Safety/Tennessee Department of Health
  • Education on Safe Sleep to parents and caregivers, by using wearable blankets and sleep sacks.

Infant Safe Sleep

  • Tennessee Department of Health Initiative – Each family will be given a “Sleep Baby, Safe and Snug” board book.

Family/Parental teaching: All parents and caregivers (daycare workers, grandparents and babysitters) will be educated on SIDS and safe sleep environments and positioning.

  1. The ABCs of sleep; Infants sleep Alone, on the Back in a C
  2. All healthy infants should be placed on their backs to sleep.
  3. All infants should be placed in a separate but proximate sleeping environment (crib, bassinette, portable crib or play yard) according to the 2016 AAP recommendations that conform to the safety standard of the United States Consumer Product Safety Commission (CPSC).
  4. All infants should be placed on a firm sleep surface. Remove all soft-loose bedding, quilts, comforters, bumper pads, pillows, stuffed animals and soft toys from the sleeping area.
  5. Never place a sleeping infant on a couch, sofa, recliner, cushioned chair, waterbed, beanbag, soft mattress, air mattress, pillow, synthetic/natural animal skin, or memory foam mattress.
  6. Avoid bed sharing with the infant.

Patient & Family Engagement

  • Tennessee Center for Patient Safety Initiative

Better focus and align with the needs of our community through a committee of former patients, family members and/or community members.

Patient Satisfaction

  • Consistently implement best practices, increase staff awareness, buy-in and involvement, to improve patient satisfaction.

Transitions of Care RN

  • Tennessee Hospital Association Coalition
  • Coleman Model
    1. Collaborate with physicians and inpatient clinical staff to identify appropriate patients for care transitions services, utilizing established criteria and to facilitate successful care transitions
    2. Provides information and guidance to the patient and/or family for an effective care transition, provides guidance to improve self-management skills and enhanced patient practitioner communication. Serves as a bridge between professional staff in a care setting for the patient and/or family
    3. Evaluates aspects of each patient’s condition, diagnoses, medications and support systems to develop an individualized plan which will lead to a successful outcome in: medication self-management, use of a personal health record, appropriate primary care and specialist follow-up and knowledge of red flags.
    4. Conduct follow-up telephone calls to participants of the program.

Stroke

  • The Joint Commission & CMS Guidelines

Medical Imaging and Laboratory total turnaround times of 45 minutes or less, upon arrival and door to needle for thrombolytic in 60 minutes.

Chronic Obstruction Pulmonary Disease (COPD)

  • American Lung Association

Provide standardized education to patients with a new diagnosis of COPD or with a history of COPD.

  1. Adopted the American Lung Association “My COPD Action Plan” http://action.lung.org/site/DocServer/action-management-plan.pdf
  1. Outpatient Pulmonary Rehab

One and Only One Campaign

  • CDC Safe Injection Practices Coalition
    To reduce the chance of transmitting infectious diseases from one patient to another by using safe injection practices.
  1. One Needle, One Patient, Only One Time

Core Measure Compliance

  • CMS Guidelines for Standard of Care & Best Practices
    1. Congestive Heart Failure (CHF)
    2. Acute Myocardial Infarction (AMI)
    3. Pneumonia (PNA)
    4. Surgical Care Improvement Project (SCIP)
    5. Stroke (STK)
    6. Sepsis (SEP)
    7. Venous Thromboembolism (VTE)
    8. Perinatal Care

Zero Patient Harm Initiatives CUSP Teams

  • Medication Process
  • Pressure Ulcer Prevalence
  • Catheter Associated Urinary Tract Infection
  • Central Line Associated Blood Stream Infection
  • Falls Prevention
  • Ventilator Associated Events
  • Surgical Site Infections
  • Hospital Acquired Infections; MRSA, VRE, C.diff and ESBL