Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. Santa Clara Valley Medical Center is committed to the delivery of high quality clinical care and services delivered in an environment that promotes safety. Strategies to ensure that quality is achieved include assessment and analysis, process redesign, and education.
Accreditation, Regulatory & Licensing
Accreditation, Regulation, and Licensing (A,R&L) provides enhanced organizational attention on compliance, survey readiness, and regulatory and licensing requirements, and contribute to successful survey outcomes. A,R &L also assesses continuous compliance with regulatory and legal requirements and standards set by accrediting agencies through internal evaluation of clinical services and operations, analysis of data, auditing and direct observation, and survey by external agencies either as a part of regular licensing and accreditation activities or in response to specific issues.
The Risk Management Department is responsible for receiving, reviewing, following up on corrective actions, and monitoring all unusual occurrence reports at Santa Clara Valley Medical Center (SCVMC) which includes inpatient and ambulatory settings. Risk Management’s primary focus is to ensure that patients are getting quality care and are safe. Errors happen in healthcare settings and with the recognition of events, there is opportunity for improvement. Risk management assures that SCVMC is in compliance with current regulations and The Joint Commission standards as it relates to risk reduction, mitigation of events, and patient safety. The department provides information, education, and trends along with the actions that are implemented to reduce medical errors and trends in the organization. Risk Management staff collaborates with providers, employees, and County Counsel as needed regarding occurrences.
The infection prevention department at SCVMC is a branch of the quality and safety program of the facility. The department, in collaboration with the epidemiology medical staff is responsible for ensuring the safety and wellbeing of the all individuals who either work at the facility, is in training at the facility or is a visitor to the facility; by limiting the risk of exposure to blood borne pathogens, multidrug resistant organisms and communicable diseases. The department is engaged in a dynamic surveillance program to identify process and outcomes measure that are not in compliance with the infection control policy manual.
Environment Health & Safety
Santa Clara Valley Medical Center’s Environmental health and Safety Service program evaluates and audits the environmental health and safety risks of various departments within the Santa Clara Valley Health and Hospital System. This includes conducting health and safety inspections, ensuring that hazardous materials and waste are handled properly, maintaining environmental permits and updating VMC’s Hazardous Materials Business Plan and Hazardous Communications program.
Quality Transparency Dashboard
Data presented in the Hospital Quality Institute (HQI)
dashboards are derived from hospital data and are reported by CDPH license
number. These Quality Transparency Dashboard Outcomes are based on data from
Santa Clara Valley Medical Center, O’Connor Hospital, and St. Louise Regional
Hospital as all three healthcare facilities share the same CDPH license,
“Santa Clara Valley Medical Center”.