Quality & Safety

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CalvertHealth is committed to our community, with a focus on patient-centered care. High quality and safe patient care is more than a goal, it is our number one priority. That means delivering the best possible care to every person, every time. We are dedicated to improving the way we do things on a continual basis. Health care inherently poses safety risks that all hospitals across the nation face. CalvertHealth acknowledges those risks and embraces the challenge to mitigate any and all potential safety events. 

Every day the team at CalvertHealth focuses on making a difference in every life we touch. For more than a century, our guiding philosophy has been to ensure the services we provide to our patients are of the highest quality. This commitment to quality and safety is evidenced by the results of our patient outcomes and the recognition received from Centers for Medicare and Medicaid Services (CMS), The Joint Commission, American Heart Association and others.

CalvertHealth's mission, vision and values guide our decision making and shape the culture of our organization. The first “value” that supports our organization is Quality. It is the foundation upon which all of our values are based. CalvertHealth provides responsible, safe, reliable and effective care and services. We take pride in what we do. Click here to learn more about what we believe.
CY 2020 Goals Accomplished
  • Initiated a nurse-driven Aspiration Protocol, assisting in identifying high- patients and initiating Speech Therapy Consults without delay
  • Reduced blood borne exposures to staff by 60%.
  • Decreased the amount of falls related to toileting by 59%, from 39 in CY2019 to 16 in CY2020.
  • Decreased patient complaints and grievances by 24% from CY2019 to CY2020.
  • Met established benchmark for medication reconciliation completed at discharge and increased performance from CY2019 by 2%.
  • Reduced hospital acquired C-diff infections by 40%, exceeding our 2020 goal.
  • Exceeded Health Services Cost Review Commission (HSCRC) benchmark for RY2021 Mortality Survival Rate of 96.96%, achieving a rate of 97.21%.
  • Achieved Quality Based Reimbursement (QBR) overall score of 42.77%, ranked eigth in the state for RY2021.

CY 2021 Goals Accomplished
  • Reduced the number of CAUTIs by 43% and CLABSIs by 20%
  • Decreased the number of ventilator-associated events by 62% in CY2021
  • Increased reporting of significant “good catches” by frontline staff by 11%
  • Reduced falls in inpatients over the age of sixty-five by 33% from CY20 to CY21

Core Measures
  • Met or exceeded all CMS benchmarks in 3 of 4 CMS inpatient metrics
  • Met CMS benchmark for the treatment of patients with severe sepsis and septic shock
  • Named as a top 10 performer for 2 Inpatient Electronic Core Quality Measures out of nearly 200 hospitals nationwide.

  • Exceeded all benchmarks for the 13 quality outcomes related to stroke
  • Achieved 100% compliance in 5 of 13 stroke metrics
  • Improved Door to Needle tPA time in less than 60 minutes from 33% of patients to 88% of patients that qualified.
  • Provided ongoing community education and involvement to provide stroke awareness:
    • Continued education for staff related to care and treatment of acute stroke.
    • Continued community outreach for education and stroke awareness by attending public events partnered with Community Wellness.

Central Line-Associated Blood Stream Infections (CLABSI)
  • In 2021, CalvertHealth reduced their total number of patient central line days by 9%; from 1196 in 2020 to 1093 in 2021, resulting in a 20% decrease in CLABSI’s. Examples of processes implemented in 2021 include the following:
    • Daily discussion of patients with Central Lines
    • Improved compliance of Chlorhexidine gluconate (CHG) baths for ICU Central Line patients
    • CLABSI education of Physicians and Nurses

Catheter-Associated Urinary Tract Infections (CAUTI)
  • 43% decrease in Catheter-associated Urinary Tract Infections (CAUTI) from 2020 to 2021.
  • The CalvertHealth CAUTI task force continues its overall goal to reduce Catheter-Associated Urinary Tract infections among its patient population. Some of the processes implemented in 2021 are as follows:
    • Retrospective reviews of nursing and provider documentation
    • Education of Physicians and Nurses on Bladder Scan Protocol
    • Daily discussions of indication and need for continuation of a urinary catheter

Surgical Site Infections (SSI)
  • Our goal at CalvertHealth Medical Center was to have an actual SIR rate that was less than the predicted rate of 2.319. While we did have 13 SSIs in 2021, our SIR rate was below the target at 2.16
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