Legacy Mount Hood Medical Center

Hospitals should provide patients with complete billing information and access to a representative that can quickly resolve billing issues. In addition, hospitals should not sue patients over late or unpaid bills.

Hospitals should examine their own data to identify any differences in processes or outcomes for patients of different races and ethnicities, and patients who speak different languages. Hospitals should also put action plans in place if differences are identified.

Hospitals should ensure that all patients are fully aware of risks and alternatives prior to procedures.

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 nurse staffing plans in place that ensure there are enough nurses of all types (i.e., registered nurses, licensed practical nurses, or unlicensed assistive personnel) to provide direct care to patients in medical, surgical, or med-surg units each day.

Hospitals should have nurse staffing plans in place that ensure there are enough registered nurses (RNs) to provide direct care to patients in medical, surgical, or med-surg units each day.

Hospitals should have nurse staffing plans in place that ensure the proportion of nursing hours performed by registered nurses (RNs) is adequate.

Hospitals should have a high proportion of highly trained and skilled registered nurses (RNs) who have an advanced nursing degree.

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 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 enter at least 85% of inpatient medication orders through the CPOE system, and should fully demonstrate their CPOE system meets the national safety standard for decision support.

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 have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, labor and delivery units, pre-operative and post-anesthesia care 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 document 90% or more of home medications, visit medications, and allergies/adverse reaction(s) in the patients’ clinical record.

Hospitals should have intensivists present on-site at least eight hours a day, seven days per week or have 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 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 have an average radiation dose for routine pediatric CT scans of the abdomen and pelvis that falls within national benchmarks.

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

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 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.

This is defined as first-time mothers giving birth to a single baby, at full-term, in the head-down position who 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 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 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 go through all the elements of a complete safe surgery checklist on all patients every time a surgery is performed.

Hospitals should ensure that a specially certified clinician is present and immediately available while an adult patient is present until discharge.

Hospitals should ensure that a specially certified clinician is present and immediately available while 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 regarding the experience of adult patients: (a) facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients' willingness to recommend the facility.

Unplanned hospital visits can occur when patients experience complications after a colonoscopy procedure. Facilities should have a rate of unplanned hospital visits that is lower than most hospitals and surgery centers.