Sponsored by Cape Fear Valley Health.
Cape Fear Valley Health takes quality control and patient safety seriously, with a comprehensive framework led by dedicated professionals and guided by strict compliance policies.
Their very ideals are written in the hospital’s vision statement — to “improve the quality of every life we touch” — and are reflected in its values: patient-centeredness, integrity, cultural diversity, innovation, teamwork, accountability and education.
Quality initiatives are overseen by a chief quality officer, and supported by a corporate compliance policy that mandates accurate documentation and continuous improvement.
Dr. Michael Ruzek is the chief quality officer for Cape Fear Valley Health and oversees performance improvement, patient safety, infection prevention, and control and regulatory readiness. His background as a board-certified physician in emergency medicine and as a leader in quality improvement helps bring clinical insight to system-wide standards.
“Our department strives to improve and standardize processes to reduce harm to our patients,” Dr. Ruzek said. “We drill down on data derived from quality metrics, incident reports, patient safety indicators and work to develop action plans to address all opportunities for improvement in these areas.”
He works with Carmelita Manning, MSN, the corporate director of quality and patient safety at Cape Fear Valley Health, who oversees quality improvement and patient safety initiatives.
Manning, who has held the position since 2024, has a 20-plus year background in nursing education and emergency nursing and has held positions as the director of nursing education and assistant vice president of emergency services for one of the largest healthcare systems in Northern, Central and Southern New Jersey.
“Most recently our department has enhanced our incident reporting system that allows us to drill down on patient safety concerns and work to eliminate harm and deviations while providing safe and efficient patient care,” Dr. Ruzek said.
He said the health system is actively working to raise the bar on quality through a mix of strategic investments, staff empowerment and data-driven initiatives.
“Our department is instrumental in working with and assisting our nursing departments to achieve the highest awards and accreditations from multiple outside entities,” Manning said.
She said that some of the more recent major achievements and awards are The Joint Commission certifications in hip/knee replacement surgery, advanced perinatal care, heart failure, pneumonia and sepsis. The Joint Commission is a nonprofit, independent organization that has set health care standards and has provided health care accreditation in the United States since 1951.
“We are also distinguished as an Advanced Primary Stroke Center and Advanced Primary Heart Attack Center,” Manning said.
The hospital system is also accredited by the American College of Cardiology and recognized as a Chest Pain Center with Primary Percutaneous Coronary Intervention (PCI). Accreditations also include the American Heart Association’s “Get with the Guidelines” in stroke and heart failure.
Dr. Ruzek and Manning said there are also various accreditations at other facilities within the system in wound care, respiratory failure and laboratory services.
The specific areas within hospital quality control, according to Dr. Ruzek and Manning, are patient safety, clinical outcomes, patient satisfaction, accreditation, compliance and risk management.
“By focusing on these areas, we regularly identify opportunities for improvement and ensure compliance with high standards of care,” Dr. Ruzek said. “We focus on these areas and involve our patients in their decision making, which leads to more personalized care, improved patient satisfaction and better health outcomes.”
He said Cape Fear Valley Health stays up-to-date with all regulatory agencies. And they maintain a corporate compliance policy that emphasizes adherence to various laws, accurate billing and documentation, confidentiality and ethical conduct.
“We willingly and at times voluntarily participate in regulatory surveys to ensure that we are providing the most optimal care to our patients,” Dr. Ruzek said. “We strive to provide care and treatment in a safe and error-free environment. We focus on quality improvement, patient satisfaction, growth and innovation, and financial stewardship with the patient in the center as our primary focus.
With each patient who comes through the doors of the hospital, Dr. Ruzek said they should expect to encounter warm and friendly staff who make them feel comfortable.
“Our patients can be assured that we are a highly reliable organization, and our top priority is to reduce harm and provide a safe, healing environment once they walk through our doors,” Dr. Ruzek said. “Every member of our community can expect to be taken care of by skilled and well-trained practitioners who take the time to understand each individual patient’s needs and concerns. Our patients should expect to receive evidence-based medical care tailored to their individual needs and have that care communicated in a way that they can understand.”
He said that patients have access to their medical information and test results through the electronic patient portal, MyChart.
“Patients also receive communication, both written and verbal, by our clinical teams, including physicians, nurses and allied healthcare clinical team members,” Dr. Ruzek said.
Quality control spans across record accuracy, staff education and compliance training, and improvement initiatives.
Further, the organization is building the new Methodist University Cape Fear Valley Health School of Medicine, which will further embed research and innovation into everyday care. They are also hosting residency programs and partnering with Methodist University and Campbell University to help train future physicians who are more likely to stay local, ensuring consistent, high-quality staffing.
Cape Fear Valley Health is not just checking boxes. They are building a culture where quality is everyone’s job.
For more information on Cape Fear Valley Health’s commitment to quality, visit capefearvalley.com.
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