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Performance Improvement

Compliance Program
The Compliance Program is a system of policies, practices and procedures that will assure that the hospital operates within all applicable federal and state laws. It includes everything from claims submission practices governed by Medicare, worker safety governed by OSHA and patient privacy laws outlined in HIPPA legislation.

Atmore Community Hospital:
Ashley Chunn, RN Office: (251) 368 - 6281

D. W. McMillan Hospital:
Debbie Gist, RN Office: (251) 809 -8279

Safety Program
The safety program exists to create a safe environment for patients, visitors and staff. We have multi-disciplinary teams participating in this effort to identify and address identified or potential safety issues.

Quality Improvement Program
Doing things right and doing the right things ... things that make the difference in our community and for our patients! The Performance Improvement department includes several functions that serve to ensure continued improvement in patient care. We manage the majority of required reporting to external agencies that aggregate and review data as well as internal committees that focus on quality of care. This includes core measures which are comprised of several diagnoses that frequently lead to hospital admission. The data focuses on compliance with best practice guidelines.

Core Measures
Our hospital delivers quality health care by using a scientifically based set of clinical measures in the treatment of our patients. This set of care processes is called core measures. The core measures were derived largely from a set of quality indicators developed by the Centers for Medicare and Medicaid Services and have evolved over time from chart abstracted measures to electronic clinical quality measures aggregated from data in our electronic health records. Core measures have been shown to reduce the risk of complications, prevent recurrences and otherwise appropriately treat the majority of patients who come to the hospital for treatment of a condition or illness. Core measures help hospitals improve the quality of care by focusing on the actual results of care.

Atmore Community Hospital:
Nichole Waller, RN Office: (251) 368 - 6339

D. W. McMillan Memorial Hospital:
Starline Sullivan, RN Office: (251) 809 - 8321

Infection Control/Employee Health Program
Infection Control is another important initiative that assures staff and patients are protected from the spread of communicable illnesses. This includes tracking of all infection data, review of culture reports and required reporting to ADPH of certain infectious conditions. This position keeps abreast of hospital policies and practices to assure we are in compliance with CDC recommendations or ADPH requirements. The Infection Control Nurse serves as the Employee Health Nurse as well. We ensure that employees are vaccinated appropriately and use Personal Protective Equipment appropriately.

Atmore Community Hospital:
Ashley Strawbridge, RN Office: (251) 368 - 6314
Click here to access Atmore Infection Control Page

D. W. McMillan Memorial Hospital:
Cindy Lancaster, RN Office: (251) 809 - 8257
Click here to access D.W. McMillan Infection Control Page

Medical Staff Office
The Medical Staff Office is a critical part of our department. Physicians and other professionals go through a very detailed application process to become members of the Medical or Allied Health Staffs. The goal is to assure that all applicants are well-trained and competent to provide healthcare services in our community.

Atmore Community Hospital:
Kim Himes Office: (251) 368 - 6396
Tara Carter, RN Office: (251) 368 - 6396

D. W. McMillan Memorial Hospital:
Hilda Brantley Office: (251) 809 - 8241