Trios Women's and Children's Hospital

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 program to combat antibiotic over-prescribing that includes all seven (7) core elements developed by the Centers for Disease Control and Prevention (CDC).

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 use a nationally endorsed protocol to track how well they are collecting and maintaining inpatient medication lists.

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 central-line associated blood stream 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.

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.

Hospitals should have fewer than expected colon infections from C. diff bacteria.

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.

Hospitals should have fewer than expected antibiotic resistant bacterial 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.

Hospitals should have fewer than expected surgical site infections after major colon surgery.

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 23.9% or less.

Hospitals should deliver at least 50 very-low birth weight babies per year and ensure that at least 90% of mothers receive antenatal steroids prior to delivery OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies and ensure that at least 90% of mothers receive antenatal steroids prior to delivery.

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.

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 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) rating facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients willingness to recommend the facility.