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Quality of Care

Our Quality Departments

Cultural Diversity Department

The Cultural Diversity Program aids staff and physicians to meet and better serve the needs of our culturally diverse population. MMH’s Language Access Services includes the Medical Interpreter Program, AT&T Language Line Services, and ASL interpreters. A Medical Interpreter can be accessed at all hours of operation. To call for an interpreter between the business hours of 8:00 A.M. to 5:00 P.M., Monday through Friday, contact the office at 432-686-5298 or cell at 432-288-4842. After 5:00 P.M., weekends, or holidays call the hospital’s operator and ask for the Medical Interpreter on call.

Infection Prevention and Control Department

The Infection Prevention and Control Department works closely with a pathologist to conduct surveillance procedures and control infections throughout the Hospital. Hours of operation are Monday through Friday, 8:00 A.M. to 4:30 P.M. Staff is available for reference by calling 685-1647 during normal business hours. Assistance can be obtained after hours by calling the Nursing Supervisor at 685-1111.

Patient Advocate Program

The Patient Advocate serves as a liaison between patients, families, hospital and medical staff, and serves as a point of contact for complaints and compliments while a patient is in the hospital. The Patient Advocate is available to assist you 24 hours a day, 7 days a week by calling the Patient Hotline number 522-2273.

Quality Management Department

The Quality Management Department is responsible for the coordination of all performance improvement activities, patient safety issues and accreditation activities. This department will also answer questions and address concerns that you may have about your hospital experience. Hours of operation for this department are Monday through Friday, 8:00 A.M. to 5:00 P.M. Assistance can be obtained after hours by calling the Nursing Supervisor at 685-1111.

The Quality Management Department has created a form to assist you in keeping track of medications that you currently take. By investing a few minutes, you can create your own personal medication record. You will then have a record of all your medications to take to your doctor’s appointment or to the hospital, in case you require care.

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Community Acquired Pneumonia

POWER POINT DOWNLOAD

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Get with the Guidelines

Midland Memorial Hospital joined the American Heart Association's "Get With The Guidelines-Coronary Artery Disease (CAD)" program in 2004, becoming the first hospital in the area to participate.

Through education and a collaborative effort between the patient and staff, the goal is to adhere to the following guidelines:

  • Lipid Management Goals
  • Diabetes Management
  • Beta blockers
  • ACE inhibitors
  • Antiplatelet/anticoagulants
  • Blood pressure control
  • Cessation of smoking
  • Physical activity
  • Weight management

AHA/ACC Secondary Prevention Guidelines
(American Heart Association/American College of Cardiology)

These guidelines have been adopted as secondary prevention. Secondary prevention refers to preventing any further heart damage after an individual has been diagnosed with heart problems or suffered a heart attack.

All patients are encouraged to know their disease process, which will enable them to be an active participant in their care. In order to help accomplish our goal, heart attack patients are provided with a Heartworks brochure. This informational guide educates the patient about the procedure and answers questions they may have after being diagnosed with a heart disease.

We are devoted to offering the best care to our heart patients and will encourage them to make lifestyle changes. Patients are also highly recommended to comply with therapies given at the time of discharge. Following this regimen will significantly reduce the chances of a reoccurrence.

 

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Hospital Quality Initiatives

(new data 12-09)

The Hospital Quality Initiatives is a snapshot of how well a hospital is caring for its patients. The hospital quality measures on this website display the recommended care for some of the most common and costly conditions that hospitals treat, which are heart attack, heart failure, pneumonia, or having surgery. Getting the recommended care means you are more likely to have better outcomes, because they are based on scientific evidence about treatments that are known to get the best results. Midland Memorial Hospital and the Centers for Medicare & Medicaid Services (CMS), along with its collaborators in the Hospital Quality Alliance (HQA) are working together to create and publicly report hospital quality information. Data for each indicator are compared to other hospitals in Texas and the U.S., and to the top 10% of hospitals in the country. The data measure how well hospitals care for their adult patients, regardless of whether the care was paid for by Medicare, Medicaid or a private health insurance plan.

You should know, however, health care experts and researchers are constantly evaluating the evidence to make sure that guidelines and measures continue to reflect the most up-to-date information. Sometimes, guidelines and measures are modified to reflect new evidence. The information you will find on this website is intended to help you start a conversation with your physician or hospital about how you can best get the care you need. There may be a specific reason you should not get a certain treatment. For instance, a recommended treatment to help prevent a heart attack is to take aspirin daily. However, you should not take aspirin if you are allergic to aspirin. Patients who should not get the recommended care are not counted in the measures.

Listed below are the performance measures reported for Midland Memorial Hospital on the HQA's website, http://www.hospitalcompare.hhs.gov. If you click on each measure's description, you can see additional details in graph form. For definitions to some of these terms, click here.

CORE MEASURES: For July 2008 through June 2009

Acute Myocardial Infarction Indicators

MMH %

National Average

1.Percent of heart attack patients given an ACE Inhibitor or ARB (medications) for left ventricular systolic dysfunction

91%

92%

2.Percent of heart attack patients given smoking cessation advice/counseling

100%

96%

3.Percent of heart attack patients given aspirin on arrival to hospital

96%

94%

4.Percent of heart attack patients prescribed aspirin at discharge

97%

93%

5.Percent of heart attack patients prescribed beta blockers at discharge

98%

94%

6.Percent of heart attack patients who received a percutaneous coronary intervention (PCI) procedures within 90 minutes of arrival to hospital

80%

81%

Congestive Heart Failure Indicators

MMH %

NationalAverage

1.Percent of heart failure patients given evaluations for left ventricular function

97%

90%

2.Percent of heart failure patients given ACE Inhibitor or ARB (medications) for left ventricular systolic dysfunction

94%

90%

3.Percent of heart failure patients given smoking cessation advise/counseling

99%

92%

4.Percent of heart failure patients given discharge instructions which include diet, activity, follow-up after discharge, medications, weight monitoring and what to do if symptoms worsen

89%

78%

Community-Acquired Pneumonia Indicators

MMH %

NationalAverage

1.Percent of pneumonia patients assessed and given pneumonia vaccines, if warranted

92%

86%

2.Percent of pneumonia patients assessed and given a flu vaccine, if warranted

88%

85%

3.Percent of pneumonia patients given initial antibiotics within 6 hours of arrival to hospital

96%

94%

4.Percent of pneumonia patients given the most appropriate initial antibiotics

80%

88%

5.Percent of pneumonia patients whose initial Emergency Room blood cultures were performed prior to the administration of the first dose of antibiotics

93%

92%

6.Percent of pneumonia patients given smoking cessation advise/counseling

95%

90%

Surgical Care Improvement Indicators

MMH %

NationalAverage

1.Percent of surgical patients given prophylactic antibiotics within 1 hour of the surgical incision

96%

91%

2.Percent of surgical patients receiving the most appropriate prophylactic antibiotic selection
95%

95%

3.Percent of surgical patients whose prophylactic antibiotics were stopped within 24 hours after surgery

94%

90%

4.Percent of surgical patient whose doctor ordered treatments to prevent blood clots for certain types of surgeries

78%

88%

5.Percent of surgical patients who received treatment to prevent blood clots within 24 hours before or after selected surgeries.

77%

86%

6.Percent of Surgery patients needing hair removal before surgery who had hair removed using a safer method.

100%

97%

7.Percent of all heart surgery patients whose blood sugar is kept under control following surgery

88%

89%

8. Percent of surgery patients who were taking a heart medication called beta blockers before coming to the hospital, who were kept on a beta blocker during the period just before surgery and after their surgery.

100%

87%

Legend

 

Performance is at or above expected range Performance is below expected range

Risk-Adjusted 30-day Mortality Rates

The following tables display a comparison of Midland Memorial Hospital's mortality rate within 30-days of admission to the hospital, to the U.S. National mortality rate for Medicare patients who were diagnosed with heart attack, heart failure or pneumonia. To make a fair comparison, the rates have been adjusted to take into account that some hospitals treat sicker patients. Hospitals are placed in the categories Better or Worse Than U.S. National Rate when there is 95% certainty that their rate is not due to chance. Hospitals placed in the category No Different Than U.S. National Rate are about the same as the national average or may be higher or lower than the average, but it is uncertain whether the difference is due to chance. The rates in the table reflect data reported for discharges July 2005 through June 2008.

For more information about the 30-day mortality rate for Heart Failure, click here.

The U.S. National 30-day Death Rate from Heart Attack

HOSPITAL NAME

Better Than U.S. National Rate

(Adjusted mortality is lower than U.S. rate)

No Different Than U.S. National Rate

(Adjusted mortality is about the same as U.S. rateor difference is uncertain)

Worse Than U.S. National Rate

(Adjusted mortality is higher than U.S. Rate)

Midland Memorial Hospital

×

The U.S. National 30-day Death Rate from Heart Failure

HOSPITAL NAME

Better Than U.S. National Rate

(Adjusted mortality is lower than U.S. Rate)

No Different Than U.S. National Rate

(Adjusted mortality is about the same as U.S. rateordifference is uncertain)

Worse Than U.S. National Rate

(Adjusted mortality is higher than U.S. Rate)

Midland Memorial Hospital

×

The U.S. National 30-day Death Rate from Pneumonia

HOSPITAL NAME

Better Than U.S. National Rate

(Adjusted mortality is lower than U.S. Rate)

No Different Than U.S. National Rate

(Adjusted mortality is about the same as U.S. rateor difference is uncertain)

Worse Than U.S. National Rate

(Adjusted mortality is higher than U.S. Rate)

Midland Memorial Hospital

×

Note:Medicare derived the 30-Day Risk-Adjusted Death (Mortality) measures from its own data about patients on Original Medicare and the hospitals that treat them. The information in this table reflects care given only to patients who are on Original Medicare.

Risk-Adjusted 30-day Readmission Rates

The following tables display a comparison of the Midland Memorial Hospital's readmission rate within 30-days after discharge from the hospital to the U.S. National readmission rate for Medicare patients who were diagnosed with heart attack, heart failure or pneumonia. "Readmission" is when patients who have had a recent hospital stay need to go to a hospital again. Hospitals are placed in the categoriesBetterorWorse Than U.S. National Ratewhen there is 95% certainty that their rate is not due to chance. Hospitals placed in the categoryNo Different Than U.S. National Rateare about the same as the national average or may be higher or lower than the average, but it is uncertain whether the difference is due to chance. The rates in the table reflect data reported for discharges July 2005 through June 2008.

Adjusted Adult Heart Attack Readmission Rates

HOSPITAL NAME

Better Than U.S. National Rate

(Adjusted mortality is lower than U.S. rate)

No Different Than U.S. National Rate

(Adjusted mortality is about the same as U.S. rate or difference is uncertain)

Worse Than U.S. National Rate

(Adjusted mortality is higher than U.S. Rate)

Midland Memorial Hospital

×

Adjusted Adult Heart Failure Readmission Rates