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Quality and Safety

Duke Regional Hospital strives to provide safe, efficient, effective, timely, and patient-centered care to all patients. All staff, executives, and providers serve as leaders in promoting the delivery of high quality health care.

The executive leadership team establishes the priorities for performance improvement, patient safety, and quality.

Leadership communicates those priorities and establishes targets for the organization’s performance through tools such as the strategic plan, the operational plan, and the balanced scorecard. In addition, the leadership team seeks to understand best practices by utilizing expert sources for benchmarking.

Duke Regional Hospital leaders are committed to fostering an environment that encourages recognition and reporting of identified risks to patient safety and quality.

Leaders demonstrate this commitment by:

  • Creating a culture of non-punitive reporting in which communication is encouraged among all disciplines, and at all levels of authority
  • Regularly evaluating the culture of quality and safety
  • Ensuring a defined, ongoing, proactive program for risk identification is fully implemented
  • Placing a high priority on questions and processes that identify risks to patient safety
  • Providing the support to measure, analyze, and manage discrepancies found in processes that affect patient safety
  • Encouraging the involvement of patients and families as vital participants in achieving health

Duke Regional Hospital is beginning to assess its processes using the world-class Baldrige criteria. Baldrige was created to recognize organizations that have outstanding processes and practices, practice measurable, continuous improvement, and achieve customer-focused performance excellence.

The Baldrige program provides organizational assessment tools and criteria, educates leaders about the practices of best-in-class organizations, and recognizes national role models with the only Presidential Award for performance excellence.

Patient Satisfaction Scores

Duke Regional Hospital and Duke Medicine began publicly reporting patient satisfaction scores in 2008.

Areas of focus include patients' perceptions of the following:

  • Communication with doctors
  • Communication with nurses
  • Responsiveness of the hospital staff
  • Pain control
  • Communication about medicines
  • Cleanliness and quietness of the physical environment
  • Discharge information
  • Overall rating of the hospital

These patient satisfaction measures were developed jointly by the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ).

The survey tool, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), provides for standardization of key quality indicators for US hospitals and lets consumers make comparisons when choosing health care facilities.

New data is added quarterly. See the most recent patient satisfaction scores on