The purpose of this newsletter is to keep all informed of the Quality Assurance and Risk Management Programs and to answer any questions.

Quality Assurance Program

Advance Directives:  (Additional Planning Information via External Website)

According to the CMS Appendix W, an Advance Directive is:

“[…] defined at 42 CFR 489.100 as ‘a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated.’”

A Patient or Resident has the right to formulate an advance directive and for the Hospital Staff to implement and comply with that information.

Information in an advance directive may include: a designated decision maker for health care, choices on what care is acceptable to the patient, and end of life decisions.

Who should have an advance directive?

Advance directives are for everyone.

Where can I find more information?

The following link goes to California Hospital Association’s Advance Healthcare Directive in English and Spanish. Instructions are included.

Reference:United States. CMS. Centers for Medicare and Medicaid Services. State Operations Manual Appendix W. Vol. Rev. 165, N.p.: CMS, 12-16-2016. PDF


Risk Management

The MCHD Safety Committee has met again this year to pick the Facility Wide Patient Safety Goals!

Selections came from the Joint Commission’s National Patient Safety Goals for Critical Access Hospitals for 2017. These will be monitored across the entire hospital.


1)   Patient Identifiers

a.    Use Patient identifiers (Name and date of birth)

b.   Verify patient identity before procedures (even non-invasive), before all medications, before lab draws


2)   Hand Hygiene.

a.    Use Hand sanitizer or wash hands with soap and water before and after every patient encounter.


3)   Reduce HAIs (Hospital acquired infections)

a.    Get catheters and invasive lines out as soon as possible.

b.   WASH those Hands!



California Hospital Patient Safety Organization (CHPSO)

CHPSO has been designated as a patient Safety Organization pursuant to the Federal Patient Safety and Quality Improvement Act of 2005.  Its purposes are to engage in:

  • Activities to improve patient safety and the quality of health care delivery.
  • Collection and analysis of patient safety work product.
  • Development and dissemination of information aimed at improving patient safety.
  • Utilization of patient safety work product to encourage a culture of safety and to provide feedback and assistance toward minimizing patient risk.

If you have any questions about your stay at Trinity Hospital, please contact Sarah Cordtz, Coordinator of Quality/Risk Management at (530) 623-5541 x3260.