MultiCare Health System

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Quality Report Card

Patient Safety


MultiCare actively participates in the Institute for Healthcare Improvement's (IHI) landmark life-saving 100,000 Lives and 5 Million Lives campaigns.

Our innovative approaches to treating heart attack patients and preventing infections are saving lives right here in our community and earning national awards.

IHI initiatives continue today at our hospitals. These life-saving interventions are:

Delivering reliable, evidence-based care for heart attacks

The national standard for time to treatment of a heart attack (the amount of time that passes between when the patient arrives at the hospital until they are stabilized) is 90 minutes. MultiCare consistently exceeds the national standards for prompt treatment of heart attacks.

Prevent adverse drug events - medication reconciliation

Medication reconciliation means that all the medicines patients receive while they are in the hospital are accurately tracked during the entire treatment. Our system-wide electronic health record system, MultiCare Connect, helps ensure that patients are receiving the correct medications and that medications given together are done so safely.

Prevent central line infections

A central line is a long, thin, flexible tube used to give medicine and fluids, inserted through a vein in the neck or chest and threaded through until it reaches a large vein near the heart. Central lines are usually left in for days or weeks and can make it possible for serious infections to enter the patient's body and threaten the patient's life. MultiCare follows a rigorous preventive program that has dramatically reduced the rate of these types of infections since 2004.

Prevent surgical site infections

An infection at the site of surgery is a common complication in hospitals. MultiCare has implemented a number of specific protocols for our surgical staff to follow to reduce the incidence of post-surgical infections. These protocols include eliminating the use of blade razors for surgical site preparation and the careful administration of pre- and post-surgery antibiotics.

Prevent ventilator-associated pneumonia (VAP)

Patients on ventilators may develop ventilator-assisted pneumonia VAP. By aggressively adhering to IHI's guidelines designed to prevent VAP, MultiCare has seen a steady decline in the VAP rate over the last three years.

Deploy Rapid Response Teams

Rapid Response Teams are a group of experts who bring critical care expertise to patients outside of MultiCare's critical care units. These teams may be called by any care provider or family member who becomes concerned about a sudden change in a patient's health or vital signs, or even if it just appears that the patient "doesn't look right." These teams empower care providers and families to call in immediate, critical care for a patient, and have helped MultiCare realize a significant drop in cardiac arrest incidents outside of critical care settings.

Hospital-Acquired Infections

As part of a statewide initiative sponsored by the Washington State Hospital Association, MultiCare Health System has set a goal to eliminate all preventable hospital-acquired infections by Jan. 1, 2012.

The WSHA pledge was signed by Diane Cecchettini, RN, President and CEO of MultiCare, along with Elise Fornadley, Marcia Johnson, Shelly Mullin, Mady Murrey, and JoEllen Vanatta, as well as executive leaders of other health care systems across Washington state.

"This is an exciting goal," said Sharon Jenkins, RN, Administrator of Quality Management at MultiCare. "By dedicating ourselves to this campaign, we are demonstrating our ongoing commitment to the quality and safety of our patients."

Within this initiative, MultiCare will focus on the following areas:

  • Central line infections
  • Hand hygiene
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • Pneumonia care
  • Staff flu immunizations
  • Surgical site infections
  • Urinary tract infections
  • Ventilator-associated pneumonia

Hospital-acquired infections can result in increased lengths of stay, increased time in the intensive care unit, and increased cost to the hospital and the patient — and sometimes they can lead to death.

Pneumonia and heart failure

These conditions commonly require hospitalization, can be fatal, and can also complicate the care of patients who are hospitalized for other conditions. Preventive care and lifestyle changes, such as receiving immunizations against pneumonia and influenza, diet and exercise changes, and managing chronic conditions such as diabetes can reduce the need for hospitalization for these conditions.

The success of the 100,000 Lives campaign led IHI to launch the 5 Million Lives campaign in December 2006, adding additional life-saving measures to protect patients from five million incidents of medical harm over the next two years.

Using the first six interventions, plus six new improvements in care, IHI aims to save more lives, reduce medically related injuries and enroll more hospitals to join in this effort.

For more information about these campaigns, and additional details on the 12 improvements in care, visit IHI's web site,

The six new interventions targeted at preventing harm are:

  • Prevent Methicillin-Resistant Staphylococcus aureus (MRSA) infection by reliably implementing scientifically proven infection control practices throughout the hospital.
  • Reduce harm from high-alert medications starting with a focus on anticoagulants, sedatives, narcotics and insulin.
  • Reduce surgical complications by reliably implementing the changes in care recommended by the Surgical Care Improvement Project (SCIP).
  • Prevent pressure ulcers by reliably using science-based guidelines for prevention of this serious and common complication.
  • Deliver reliable, evidence-based care for congestive heart failure to reduce readmissions.
  • Get hospital boards involved and engaged by defining and implementing new and leveraged processes.