12 1 3-2 Project Preparation: Quick Check Royce Cleary Southern New Hampshire

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3-2 Project Preparation: Quick Check

Royce Cleary

Southern New Hampshire University

IHP 604: Healthcare Quality Improvement

Dr. Patricia Thompson, DNP, RN

02 June 2024

Selection of Healthcare Organization

The healthcare organization chosen for the focus of this report is Memorial Satilla Health.  Formerly known as Satilla Regional Medical Center, this healthcare facility was bought by HCA Healthcare in 2017 and renamed (American Hospital Directory, n.d).  This hospital, located in Waycross, GA, is designated as an Inpatient Rehabilitation Facility (IRF) and is listed as a nonprofit corporation.  Inpatient Rehabilitation Facilities are free-standing rehabilitation hospitals and rehabilitation units in acute care hospitals for patients who are able to tolerate three hours of intense rehabilitation services per day (Centers for Medicare & Medicaid Services, nd).

Selection of Public-Facing Data

The quality improvement plan uses data made available to the public. This data comes from the CMS care compare tool. All facilities are required to submit data that meets Medicare standards. In terms of reporting, specific data points of focus have been identified. In this instance, the one area of focus is the success rate when going from the facility back to home.

Discuss Your Selections

The decision to focus on Memorial Satilla Hospital was based on data from the CMS Care Compare tool (2022), indicating that the successful return to home and community rate stood at 57.99% compared to the national average of 66.93%. This discrepancy raises essential questions about the effectiveness of the medical facility’s current rehabilitation practices, patient outcomes, and potential areas for improvement.  According to the Centers for Medicare & Medicaid Services (CMS) (2022), this facility treated around 274 patients with various conditions ranging from amputations to neuromuscular disease.  Middleton et al. (2018) described a retrospective study involving Medicare beneficiaries (487,862 individuals) who achieved successful returns.  The study of the covered 1,154 IRFs revealed that 63.7% of these patients experienced a successful community discharge, almost equaling the present national average.  Drawing on the findings of Middleton et al. (2018), it is evident that a quality improvement initiative is crucial for enhancing patient outcomes.

References

Medicare.gov. (n.d.). Find healthcare providers: Compare care near you. Medicare. https://www.medicare.gov/care-compare/details/inpatient-rehabilitation/11T003?city=Waycross&state=GA&zipcode=

Centers for Medicare and Medicaid Services. (n.d.). Inpatient rehabilitation facilities. CMS.gov. https://www.cms.gov/medicare/health-safety-standards/certification-compliance/inpatient-rehabilitation-facilities#:~:text=IRFsarefreestandingrehabilitation,intenserehabilitationservicesperday.

Middleton, A., Graham, J. E., Bettger, J. P., Haas, A., & Ottenbacher, K. J. (2018, November 2). Facility and Geographic Variation in Rates of Successful Community Discharge After Inpatient Rehabilitation Among Medicare Fee-for-Service Beneficiaries. Europe PMC. https://europepmc.org/article/MED/30646352