Quality report: zero falls with injury for six months, infection metrics strong but Cerner data gap flagged

Christy Lewis, the hospital’s chief compliance officer, presented the quality report on March 26 and told the board the hospital has had "0 falls with injuries for 6 consecutive months," sustained benchmark‑beating hand‑hygiene rates and exceeded barcode medication administration adherence of 95% for 11 consecutive months.

Lewis also highlighted infection metrics: the hospital reported a year without incidences for central‑line associated bloodstream infections, catheter‑associated urinary tract infections and MRSA bacteremia in the datasets available to the board. She said surgical site metrics (including hysterectomy and C‑section measures) also showed improvement.

Lewis signaled an important data limitation: some graphs in the board packet contained gray areas where the team could not extract reports from the Cerner electronic health record for January. "We are going to go back and use a statistically valid sample size for our charts, and we are going to start doing those by hand until that we have that remediated," she told the board. The team plans to include February’s numbers in the next quarterly report once the issue is fixed.

Lewis reported sepsis bundle compliance improving into the mid‑60s (reported as roughly 63.6% improving to ~64.4% in February) and told the board that the hospital is back in good standing with CMS conditions of participation, which preserves Medicare participation for the hospital.

The board moved to approve the quality report by voice vote after a short question period about whether post‑discharge clinic visits would capture later surgical‑site infections. Lewis said the current data capture reflects in‑hospital events but that she would include outpatient follow‑up data if requested.