San Andreas, CA…Mark Twain Medical Center is one of only 21 facilities across the nation – and, the only one in California – to be named a Top Rural Hospital of 2016 by The Leapfrog Hospital Survey. This independent, nonprofit hospital watchdog organization recognizes excellence in patient safety and quality care. In addition, MTMC is currently ranked in a tie for second place in Dignity Health’s No Harm Campaign, an ongoing quality care and patient safety ranking among its 39 hospitals nationwide. The local facility also ranks near the top in the annual Hospital Quality Report from Dignity Health.

Pictured MTMC Staff: Back row: Natalie Hammond, RN; Nancy Hiteshew, RN, Director of Quality, Risk, Compliance & Privacy; Margaret Pyles, Manager of Human Resources; Deborah Cline, RN, Education Manager; Front row: Micky Kammerer, RN, House Supervisor; Kristine Dittman, RN, Emergency Department Manager; Susan Wright, Occupational Therapist.

According to Nancy Hiteshew, Director of Quality, Risk, Compliance & Privacy, MTMC earns such high-profile recognition because “everyone here is engaged in being top performers and providing safe, quality care for all patients.” Her credentials – MSN, RN, CPHQ, CEN, CPEN, CCRN, CNL – reflect a distinguished career as an ER nurse which is ongoing in addition to her MTMC role.

“I work one weekend a month in the Emergency Department of a level 3 trauma center in Napa, CA,” she explains. “I do it to keep up my skills because I want to be credible when I’m talking quality care. And, I love nursing. It is a profession that truly makes a difference.”

Nancy emphasizes that the front line nursing staff is key to quality control successes at MTMC. “When we share data with them they know how to make things better with real time communication. It all results in a healthier community. It’s a team effort – not from the top down, but from the front line up.

Nancy explains recent recognition results from MTMC’s underlying commitment to standards for quality measures data collection set by The Joint Commission and The Centers for Medicare and Medicaid Services (CMS). “Data is pulled from electronic chart abstraction – there is no way to skew the information.” Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. CMS sets standards that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs.

Nancy assures MTMC adheres to these high standards which ultimately can lead to industry recognition like the Top Rural Hospital designation by The Leapfrog Hospital Survey. It compares hospitals’ performance on national standards of patient safety, quality, efficiency and management structures that prevent errors, providing the most comprehensive picture of how patients fare at individual institutions.

The data collected also enables hospitals to benchmark their progress towards Leapfrog’s standards and measure the care they deliver.

It is an elite national distinction given to hospitals with the highest quality in the nation. Performance across significant areas of hospital care, including safety, surgical outcomes and leadership, is considered in establishing the qualifications for the award. Data is gathered and publicly reported through the Leapfrog Hospital Survey.

Measurements include computerized physician order entry, which eliminates misinterpretation of hand written orders; evidence-based hospital referrals; Intensive Care Unit physician staffing; safe practices; managing serious errors; bar coded medication administration and readmission for common acute conditions.

Nancy explains that Dignity Health is one of several health care organizations contracted with CMS to combat hospital-acquired conditions. That is the purpose of the No Harm Campaign. MTMC currently scores 95 out of 100 points – tying for second place across the Dignity Health system nationwide.

“We will get to 100 very soon,” she smiles. This rank is based upon no adverse drug events, no catheter associated urinary tract infections, no blood stream infections, no falls with injury, low sepsis mortality, no surgical site infections and no colon infections. Last year, Dignity Health also recognized MTMC for one of the system’s lowest sepsis mortality rates.

“Our approach to quality issues is unique,” Nancy notes. “Most big hospitals have a quality control staff that collects and analyses data. Here, I am a two-person department accessing data and then sharing it with physicians, management and front-line staff. Any concern is treated as an educational opportunity.”

Nancy came to MTMC two years ago from Kaiser’s Regional Office in Oakland where she oversaw quality issues for 21 hospitals across Northern California. She specialized in sepsis mortality reduction and ICU mortality reduction, while at the same time continuing her ER nursing responsibilities in Napa.

She has two adult children – Angela, who is a criminalist with the Contra Costa County Crime Lab and Anthony, who is in the U.S. Air Force and currently in pilot training at Columbus Air Force Base in Mississippi.

Nancy and her boyfriend Jerry Bonomi, a retired firefighter, are motorcycle enthusiasts and traveled the roads of Calaveras County for many years before purchasing property in Burson in 2009. “It was meant as a vacation getaway,” she notes. “But, it quickly became our permanent home. We love Calaveras County.”

She says, “I’m really proud of what’s happening here at MTMC. If I ever have to be a patient – this is where I want to be.”

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About Mark Twain Medical Center
Founded in 1951, Mark Twain Medical Center is a 25-bed, critical access hospital providing inpatient acute care, outpatient services and emergency services. The Medical Center’s Medical Staff represents a broad range of specialties that ensure access to high quality medical care in a rural community. In addition to being a major provider of health services, Mark Twain Medical Center is also one of the area’s largest employers. More than 300 people are employed at the hospital and its five Family Medical Centers. The Medical Center is a member of Dignity Health, the fifth largest not-for-profit healthcare system in the nation. For more information, please visit our website at www.marktwainmedicalcenter.org. Mark Twain Medical Center is also on Facebook.