Quality of Care
Tri-County Health Care is committed to providing quality health care to the communities it serves. Quality care is measureable through clinical quality measures, patient safety initiatives, performance improvement measures and patient experience scores. Health care is an ever changing environment and Tri-County Health Care maintains high standards to keep quality care a priority.
Community Health Needs Assessment
Tri-County Health Care completed a Community Health Needs Assessment (CHNA) to better understand the health needs in our local communities. This assessment of residents in the TCHC service area will help us better serve our patients and encourage them to make healthy decisions to positively impact their lives. The CHNA also responds to IRS community benefit regulatory requirements.
Download a pdf version here.
A printed version is available for viewing at Tri-County Health Care in the Administrative Suite during regular business hours.
Tri-County; A Joint Commission 'Top Performer'
Tri-County Hospital has been named one of the nation's top performers for attaining and sustaining excellence in key quality measures by Joint Commission, the leading accreditor of health care organizations in the United States. The Top Performer program recognizes accredited hospitals that attain and sustain excellence in accountability measure performance. Tri-County represents the top 37 percent of all Joint Commission-accredited hospitals that reported accountability measure performance for 2013 and are being recognized for our achievement in Pneumonia and Surgical Care.
Tri-County Hospital is one of 22 of the 143 Minnesota hospitals to be recognized by The Joint Commission as a Top Performer on Key Quality Measures. This distinguished award recognizes Tri-County's commitment to assuring that evidence-based interventions are delivered in the right way and at the right time—because it's the right thing to do for our patients.
"Shorter hospital stays, fewer complications, quicker recovery, fewer return visits after receiving care—these are things that all of us want and quite frankly deserve as patients—what I would expect and demand for myself and my family," said Joel Beiswenger, Tri-County Health Care President and CEO. "Tri-County is evaluated on these measures each and every year, and I am proud to say that we are not only meeting, but we are exceeding these national standards."
To be recognized as a top performer, Tri-County Hospital had to:
- Achieve cumulative performance of 95 percent or above across all accountability measures.
- Achieve performance of 95 percent or above on each and every reported accountability measure where they are at least 30 denominator cases.
- Have at least one core measure set that has a composite rate of 95 percent or above, and (within the measure set) all applicable individual accountability measures have a performance rate of 95 percent or above.
A 95 percent score means a hospital provided an evidence-based practice 95 times out of 100 opportunities to provide the practice.
"Each accountability measure represent an evidence-based practice," said Tammy Suchy, Director of Quality and Risk Management/Compliance Officer. "For example, the appropriate antibiotics are started within one hour prior to the surgical incision, allowing time for the antibiotics to get into the system; the appropriate action is taken to prevent blood clots; and, if you are admitted for community-acquired pneumonia that appropriate antibiotics are given to treat it."
The Joint Commission continues to be a leader in performance measurement and is the nation's oldest and largest standards-setting and accrediting body in health care. Quality improvements in hospitals contributes to saved lives, better health and quality of life for many patients, as well as lower health care costs.
"This distinction is significant because it is based on evidence-based interventions that lead to better patient outcomes," said Beiswenger. "This recognition by the Joint Commission is made possible because of our staff's dedication to our community. Their hard work, commitment to their patients and ability to work as a team makes a difference."
In addition to the Top Performer on Key Quality Measure, Tri-County Health Care has received the Gold Seal of Approval™.
Quality measures are established according to current evidence based standards of care. Standards of care are developed by many health care organizations such as: American College of Cardiology, American Heart Association, Center for Disease Control, etc.
These best practices can be measured to maintain quality care throughout the organization.
Transforming Care at Tri-County
Transforming Care at Tri-County (TCAT) is an initiative started in 2008 as TCAB (Transforming Care at the Bedside) with our nursing department and evolving to an all-inclusive program charged with exploring improvement projects within all areas of Tri-County. TCAT projects originate from our staff members who see an improvement opportunity within their own department.
TCAT Project Example: Lab Orders Project
This spring, a handful of staff took the initiative to improve how the laboratory department functions. Seven staff members formed a task force to take on this newly created initiative. They met for four consecutive days to brainstorm what they could do better to maximize the efficiency of the process.
The goal was to improve patient outcomes, as well as make it a better place for staff. "Engagement was essential in all levels for this to succeed," said Tammy Suchy, Director of Quality and Risk Management. "Anytime we can streamline the process and eliminate waste we improve patient, provider and employee engagement and satisfaction."
The lab task force worked to streamline lab orders, decrease wait times (thus improving patient satisfaction), clarify lab orders for staff (thus promoting patient safety and minimizing their confusion) and improve lab result turnaround time.
This project also caught the attention of Minnesota Department of Health (MDH) staff during a recent site visit. "The MDH staff was very impressed with all that is going on at Tri-County, specifically noting the lab orders project," said Judy White, Vice President of Clinic Operations.
Bill of Rights
Tri-County Health Care is committed to providing a high standard of care, safety and hospitality for patients and their families. Our organization strives to provide comprehensive, quality health care in a spirit of personal caring, safety and concern. In an effort to accomplish this goal, we believe that you, as our patient, and/or your significant other may have the responsibility to make decisions regarding your health care.
It is the policy of Tri-County Health Care to support and care for all patients in a manner and an environment that promotes quality of life with emphasis placed on dignity, choice and self-determination. In addition, Tri-County Health Care will strive to protect and promote patients' rights and responsibilities without interference, coercion or discrimination.
- You have the right to receive considerate, respectful, compassionate and appropriate care regardless of your age, gender, race, national origin, religion, sexual orientation, culture, language, socioeconomic status or physical or mental disabilities.
- You have the right to have your cultural and personal values, beliefs and preferences respected.
- You have the right to be treated by medical and non-medical personnel with consideration, dignity and respect, in a safe environment that is free from all forms of abuse, neglect, harassment and/or exploitation.
- You can expect full consideration of your privacy and confidentiality in care discussions, examinations and treatments. You may ask for a chaperone during any type of examination.
- You have the right to access protective and advocacy services or have these services accessed on your behalf in cases of abuse or neglect. A list can be made available at your request.
- You have the right to access and accommodation of religious and other spiritual services.
- You have the right to designate visitors, including but not limited to spouse, domestic partner, family members, friends and the right to withdraw or deny consent at any time. It is our goal to ensure that all visitors enjoy full and equal visitation privileges consistent with patient, or appointed decision maker preferences.
- You have the right to examine and receive an explanation of your bill regardless of your source of payment.
- You have the right to have your pain assessed and to be involved in decisions about managing your pain.
- You have the right to remain free from seclusion or restraints of any form not medically required.
- You have the right to receive reasonable continuity of care.
- You have the right to have your primary physician promptly notified of your admission to this hospital.
- You have the right to be called by your proper name.
- You have the right to be told the name(s) of the physician(s) who has/have the primary responsibility for coordinating your care and other health care team members involved in your care.
- You have the right to have all of your patient's rights apply to the person who may have legal responsibility to make decisions regarding medical care on your behalf including the right to refuse care, treatment and services on the patient's behalf in accordance with law and regulation.
- You and your family members or friends, with your permission, have the right to participate in decisions about your care, treatment and services provided, including the right to refuse treatment to the extent permitted by law. If you leave the hospital against the advice of your doctor, the hospital and doctors will not be responsible for any medical consequences that may occur.
- You, or your surrogate decision maker, have the right to receive information from your physician about your illness, course of treatment, outcomes of care (including unanticipated outcomes) and your prospects for recovery in terms that you can understand.
- You have the right to participate in the development and implementation of your care and actively participate in decisions regarding your medical care. To the extent permitted by law, this includes your right to request or refuse treatment.
- You have the right to obtain from your physician information concerning current diagnosis, treatment plan (including risks and benefits), alternate plans and prognoses in order to give informed consent or refuse treatment. In the event that you choose to refuse treatment, you have the right to be informed of the medical consequences of that decision.
- You have the right to agree or refuse to take part in medical research studies. You may at any time withdraw from a study.
- You can expect that all communication and records about your care are confidential, unless disclosure is allowed by law. You have the right to see or get a copy of your medical records and have that information explained, within a reasonable time frame. Written permission will be obtained from you, or the person who has legal responsibility to make decisions for you, before medical records are released to anyone not directly related and/or involved in your care.
- You have the right to formulate advance directives regarding your health care, and have hospital staff and practitioners who provide care in the hospital comply with these directives (to the extent provided by state laws and regulations). If you do not have an advance directive, we can provide you with information and assist you in completing one.
- You have the right to be communicated with in a manner that meets your needs. This may include sign language or foreign language interpreter services. We will provide services as needed.
- You, or a family member, has the right to discuss any ethical issues as they relate to your care. You may contact the hospital social worker, in-patient nurse manager or the director of patient care services to discuss these concerns.
- You have the right to be involved in your discharge plan. You can expect to be told in a timely manner of the need for planning your discharge or transfer to another facility or level of care.
- You have the right to voice your concerns about the care you receive. If you have a problem, or complaint, you may talk with your physician, the inpatient nurse manager, director of patient care services, or the hospital social worker.
Contact for the Department of Health:
Office of Health Facility Complaints
85 E. Seventh Place, Suite 220
P.O. Box 64970
St. Paul, MN 55164-0970
651-201-4201 or 800-369-7994
Minnesota Board of Medical Practice
2829 University Ave. SE, Suite 500
Minneapolis, MN 55414-3246
612-617-2130 or 800-657-3709
- Provide accurate and up-to-date information regarding your health and report any changes in how you feel to your health care providers.
- Ask questions until the plan of medical treatment is clearly understood.
- Make informed decisions.
- Follow the chosen treatment plan, know the medications you are taking, know who is taking care of you and know your health insurance coverage.
- If you have one, provide a copy of your advance directive to your caregiver.
- Respect others' privacy and property and assist staff in the control of noise, smoking and the number of visitors.
Code of Ethics
The goal of the Code of Ethics is to support and protect the rights of patients in all aspects of health care provided by the staff at Tri-County Health Care. They are based on the following principles:
- To meet the needs of patients and their families to the best of our ability
- To act in good faith: to be honest, truthful and fair to all
- To maintain the highest level of skill and expertise in the delivery of care
The above statements are the foundation to which the following scope of services relate:
- Marketing efforts will not mislead the public or misrepresent the facility as to the types or quality of services available.
- Admission to or transfer from Tri-County Health Care facilities is not based on patient or facility economics or incentives. Decisions on admission or transfer will be made in cooperation with the patient, the attending physician and other involved care providers. The best interests of the patient and family will be the primary motivating factors in all decisions.
- Patient care: All patients will be treated with respect, their dignity and privacy will be maintained at all times, and they will be given the information they need to be wise consumers of health care at Tri-County Health Care. Confidentiality and privacy compliance with patient information is a right that can be expected at Tri-County Health Care.
- Transfer: Should the patient require or request services not available or inconsistent with the organization's mission, transfer to a facility prepared to fulfill this need will be offered.
- Discharge: Patients will be discharged when the physician, care team and patient are in agreement that treatment goals have been met or can safely be provided in another setting. If there is a disagreement regarding discharge, concerns regarding early discharge will be handled by the Performance Improvement Committee.
- Billing and resolution of conflicts associated with patient billing: All patients have the right to a formal review of their itemized bill and to ask questions about charges. All customers will be treated with respect in an honest, decent and professional manner. Patients have a right for this process occur as expeditiously as possible. If this does not happen, patients will be given the opportunity to voice their concern to a facility patient advocate, and it will be handled according to the compliance/grievance procedure.
- The Governing Board will disclose any conflict of interest they may have that could influence their relationship or service to Tri-County Health Care.
Standards of Care
At Tri-County Health Care, we strive to be the health care provider where patients choose to receive care, physicians choose to practice and where employees choose to work.
Because Tri-County Health Care CARES about our patients, families and employees, we will be: Courteous, Attentive, Respectful, Enthusiastic, and Safe. With this goal in mind, we developed these standards of excellence. The standards establish specific behaviors that all employees and practitioners are required to adhere to while on duty and when representing Tri-County Health Care.
To meet this standard I will:
- not discuss workplace issues with or in the presence of our patients, residents, their families or other visitors.
- not blame another person or department for shortcomings in our process or organization.
- take pride in the appearance of all Tri-County Health Care locations.
- put a smile in my voice and answer the telephone with a pleasant greeting, department reached and give the caller my name.
- refrain from speaking on the phone when eating or chewing gum.
- ask a caller’s permission before placing them on hold and provide a reason for doing so.
To meet this standard I will:
- take responsibility for problem solving; not only recognizing the concern but helping to bring suggestions for improvements to the discussion table.
- call my customer by name as soon as I have heard or seen it.
- embrace the concept that our patients & residents are our reason for being here.
- remember and use the acronym of HEAL: Hear what the customer is saying, Empathize & seek to understand, Apologize if something isn’t right, Leap into action to solve the concern.
To meet this standard I will:
- safeguard and protect the confidentiality of the information I have access to in my work; visual, verbal, written and computerized.
- not access patient information unless I have a valid work-related reason to do so.
- respect the dignity of all and will show empathy and consideration in our words and actions.
- annually sign and follow the privacy and security rules and regulations of TCHC.
- demonstrate my respect for our customers and our institution through my behavior, my words
- and even my dress. I will dress appropriately, adhering to the department’s dress code. I will present a positive image of Tri-County Health Care in all my interactions.
Enthusiastic Team Members
To meet this standard I will:
- promote a culture that helps my team members feel appreciated, included and valued.
- serve as a team member assisting my teammates in our efforts to provide exceptional customer service.
- manage up my fellow team members, physicians and departments by taking every opportunity to cast them in a positive light.
- do my part to eliminate harmful & hurtful gossip in the workplace.
- give positive recognition in public; and coach in private.
To meet this standard I will:
- value my own safety and the safety of others by promptly reporting safety concerns.
- help to create a safe health care environment for our customers and fellow team members by following infection control policies.
- report any possible security violations or threats on any of TCHC campus sites to my manager or to the staff person in charge of the site.
- be responsible for the security of my personal identification badge and any facility keys issued to me.
Our patients, residents and their families have placed their confidence and their care in our hands – for this we are honored. It is the manner in which we live up to this task which determines our success.