Quality Management System

Berry Lovering: MSN, RN Quality Assurance & Risk Management Director

 

  • Patient-Centered Care – Ensuring every decision and improvement initiative prioritizes patient safety, comfort, and outcomes.
  • Continuous Improvement– Using evidence-based practices and data-driven strategies to enhance care quality and efficiency. The data collection and    process reviews guides the facility in preventing harm.
  • Regulatory Compliance – Meeting and exceeding state, federal, and CMS quality reporting requirements, including MBQIP measures. MBQIP is the Medicare        Beneficiary Quality Improvement Project. Compliance is demonstrated through a rigorous site visit survey by an accrediting agency.      We are accredited by ACHC.
  • Performance Monitoring – Tracking key quality indicators to identify trends, address gaps, and celebrate successes. A few examples include patient falls,    hospital acquired infections, ER throughput.
  • Staff Education & Training – Providing ongoing learning opportunities to keep our team current with best practices and innovations.
  • Infection Prevention & Safety – Implementing proactive measures to reduce risks and maintain a safe environment for patients, visitors, and staff.
  • Community Engagement – Partnering with patients, families, and local organizations to improve health outcomes in our community.
  • Transparency & Accountability – Sharing quality performance results to build trust and demonstrate our commitment to excellence. The data is reviewed and discussed with all hospital leaders and staff.