Marshall Medical Center
Placerville, CA

Estimated patient harm events prevented (2012-2013, Q3): 1631

Estimated cost savings: $1,496,8481

Marshal Medical Center (MMC) successfully reduced Harm-Across-the-Board statistics by 81 percent from first quarter 2010 through second quarter 2013. Areas of applicable harm include:

  • catheter-associated urinary tract infection (CAUTI)
  • central line-associated bloodstream infection (CLABSI)
  • hospital acquired pressure ulcers (HAPU)
  • surgical site infection (SSI)
  • ventilator-associated pneumonia (VAP)
  • venous thromboembolism (VTE)
  • early elective delivery (EED)
  • Falls with Injury

MMC attributes their success to a leadership team skilled in creating organization quality and safety goals that were communicated to the entire hospital staff with regular updates of change. The leadership team included the Vice President of Quality as part of the senior team, as well as Performance Improvement (PI) Specialists and Infection Preventionists throughout the hospital, embedded in Home Care, Med/Surg, and Teleunits. MMC also boasts a well-developed culture of patient safety that was evidence in the top quartile performance of 10 of the 12 AHRQ Hospital Culture of Patient Safety Dimensions in 2012.

MMC created three strategies to help drive positive results throughout the organization:

  • Multidisciplinary process improvement teams consisting of frontline staff, physicians, PI specialists and an executive champion
  • Improved event analysis to enhance learning & mitigation harm
  • Acknowledgement of harm reduction within units and across organization

MMC has met zero harm in some areas and pledges the following future actions to maintain success in improvement:

  • Eliminate CAUTIs at Marshall Medical Center – Continue to create a reliable process for insertion and timely removal.
  • Reduce SSI by at least 40% from a 2011 Baseline Rate of 1.9 to an average rate of no more than 1.1 by September, 2013. (Completed)
  • Continue to enhance Event Analysis methodology to increase learning from errors and mitigating harm.
  • Support managers’ communication of reported harm events within each unit and across the organization to heighten learning from errors.

HQI commends Marshall Medical Center’s ongoing efforts to create an environment that promotes quality improvement and patient safety throughout the organization. Congratulations to James Whipple, CEO; Kassie Waters, Director of Quality Improvement; and the entire team for accomplishments and continued dedication.

Marshall Medical Center, Placerville, California, opened in 1959.  Independent, nonprofit, 113 beds, over 190 affiliated physicians and 1200 employees providing care to more than 150,000 residents in El Dorado County, California.


1. HRET Improvement Calculator using data from the HRET CDS