Methodist Hospitals - Northlake Campus

Hospitals should take meaningful steps to raise awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resources to implement a patient safety program, and develop systems and structures to support action to improve patient safety.

Hospitals should assess their culture of safety and hold leadership accountable for implementing policies, procedures, and staff education to improve the culture of safety.

Hospitals should assess their nursing staff levels and core competencies, included nurses in leadership, and develop and implement plans to address any areas of improvement.

Hospitals should regularly monitor hand hygiene practices for everyone interacting with patients, and give feedback to ensure compliance. Hospitals should foster a culture of good hand hygiene, offer training and education, and provide equipment, such as paper towels, soap dispensers, and hand sanitizer.

Hospitals should have a never events policy that includes all nine (9) actions that should occur following a “never event,” which includes apologizing to the patient and not charging for costs associated with the never event. 

Hospitals should have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, and labor and delivery units to scan the patient and medication prior to administration at least 95% of the time. The BCMA system includes decision support to prevent errors and the hospital has processes to prevent workarounds.

Hospitals should enter at least 85% of inpatient medication orders through the CPOE system.

Hospitals should have a rate of unintentional medication discrepancies per medication that is lower than or equal to the 50th percentile (where lower performance is better) nationally.

Hospitals should document 90% or more of home medications, visit medications, and allergies/adverse reaction(s) in the patients’ clinical record.

Hospitals should have fewer than expected catheter-associated urinary tract infections. 

Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected.

This is defined as first-time mothers giving birth to a single baby, at full-term, in the head-down position deliver their babies through a C-section. Hospitals should have a rate of C-sections of 23.6% or less.

This is defined as mothers being scheduled for cesarean sections or medication inductions prior to 39 weeks gestation without a medical reason. Hospitals should have a rate of early elective deliveries of 5% or less.

This is defined as mothers having an incision made in the perineum (the birth canal) during childbirth. Hospitals should have a rate of episiotomies of 5% or less.

Hospitals should screen at least 90% of babies for jaundice.

At least 90% of women undergoing a cesarean section receive treatment to prevent blood clots.

Hospitals should deliver at least 50 very-low birth weight babies per year OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies.

Hospitals should perform better than most hospitals in five (5) areas:

1. Communication with Parent – Communication about your child’s medicines
2. Communication with Parent – Keeping you informed about your child’s care
3. Communication with Child – How well nurses communicate with your child
4. Communication with Child – How well doctors communicate with your child
5. Attention to Safety and Comfort – Preventing mistakes and helping you report concerns.

Hospitals should use a CT radiation dose for routine CT scans of the abdomen and pelvis that falls within national benchmarks.

Hospitals should have an average radiation dose for routine CT scans of the head that falls within national benchmarks.

Hospitals should have intensivists present on-site at least eight hours a day, seven days per week or has intensivists present via 24/7 telemedicine with some on-site intensivist presence. When not in the ICU, the intensivist immediately responds to calls and has another physician or trained clinician who can immediately reach the patient.

Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. 

Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. In addition, hospitals should participate in a national clinical registry and achieve the same or better outcomes when compared to others who also perform this procedure.

Hospitals should perform at least 10 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually.

Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually.

Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. 

Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually.

The hospital performs at least 20 procedures annually, and as part of their process for privileging surgeons, ensures that each surgeon performs at least 10 procedures annually. 

Hospitals should perform at least 16 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 6 procedures annually.

Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually.

Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually.

Hospitals should perform at least 8 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 5 procedures annually.

Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while an adult patient is present until discharge.

Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while a pediatric patient is present until discharge.

Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a procedure is performed.

Hospitals should perform better than most on four (4) areas including: (a) facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients willingness to recommend the facility.