Empirical Quality Results

At Jackson, we’re committed to offering excellent care to each patient we serve. To achieve excellent care, we work hard to improve existing processes and create new processes based on evidence-based practice.

Reaching zero harm through innovation and exemplary practices

NICU Celebrated 1,000 days CLABSI-free

Accordion

  • In October 2021, the NICU celebrated 1000 days CLABSI-free
  • In 2021 the NICU surpassed this milestone nearly reaching 3 full years without a CLABSI

  • Premature infants are vulnerable to CLABSIs because they require intravenous access for up to several weeks of months until they can tolerate feeds
  • CLABSIs can increase their length of stay by 19 days and may cost up to $90K to properly care for them
  • Our teams are passionate about caring for their parents because our goal is to get them home safely

  • External collaboration with Florida Perinatal Quality Collaborative
  • Standardization of practices and evidence-based prevention bundles
  • Caregiver engagement and agency as project champions
  • Clear expectations from accountable leaders

Jackson North Medical Center one year of being CAUTI-Free

Accordion

  • On March 31, 2021, Jackson North celebrated 365 days of being CAUTI-FREE.

Improving Patient/Quality Outcomes through Exemplary and Evidence-Based Practices

Jackson Behavioral Health Hospital

Accordion

Improved patient experience scores by approximately 10 percent from 2020’ss already high-top box percentage:

  • Nurse leader rounding
  • Development and implementation of behavioral health CARE guides
  • Therapeutic programming improvements in pediatric, geriatric, and substance use disorder units

All IPFQR measures exceeded national average for the year, except tobacco use screening and tobacco use treatment provided or offered (the latter due to a Cerner programming issue which has since been rectified).

  • Inclusion of select metrics in daily huddle
  • Posting updated scorecards monthly and reinforcing in staff meetings
  • Scanning transition records
  • Nursing leadership access to lab fallout report daily
  • Coaching and corrective action for repeated fallouts

Accordion

Patient Flow
Met our goal for the year of >60 percent patients discharged before 1 p.m.:

  • Early discharge orders
  • Priority matrix utilization
  • Valuables, belongings, discharge medication standardized process

Decreased ED length of stay for all patients, especially our sickest patients (ESI 1)

  • Standard workflow and checklist
  • Hourly huddles

Admissions (“heads in beds”) before midnight-met goal of fewer than 20 percent missed opportunities:

  • AIC 11 p.m. rounds
  • AIC nightly accountability email to leadership

Falls that occur during a patient’s hospitalization can lead to serious injury and increase both their length of stay and hospital cost. Jackson System strives to prevent falls by promoting a culture of safety and foster an environment of care to reduce the incidence of patient falls and minimize the risk of injury. As a result of this commitment, initiatives were put in place to promote caregiver rounding, quick staff response to bed and chair alarms, and increased staff awareness of safety equipment and patient risk factors.

Behavioral health inpatient falls per 1000 patient days decreased by 14% and falls with injury per 1000 patient days decreased by 26% from FY 2020 rates.

  • Gerimed unit: New medical beds with falls alarms, toileting rounds
  • Co-occurring disorder unit: (non-ligature) call bells