Case Study

Wanted: Ideas to improve this patient's experience

As an organization, Hallmark Health System (HHS) works tirelessly to ensure a culture of safety and that each patient receives the highest quality of care through every interaction. This includes taking into account how a patient perceives the way care is being delivered. Recently, HHS President and CEO Michael Sack received a letter from a patient who said she arrived at the Emergency Department at 7 a.m., was told that she would be admitted, waited all day before she was brought to the floor, had trouble with an IV and was awakened in the middle of the night for a blood draw. Her perception is that little was done to take care of her leaking IV or inform her of the time it would take to admit her to the floor. By the time she got to the nursing unit in the early evening, she was exhausted and then awakened at 3 a.m. for a procedure. She was discharged only to be asked to come back to remove her IV, which was done in a non-patient care area.

“This is an unfortunate example of a lot of things not going right for this patient,” said Sack. “Good intentions did not get the job done. In a busy environment we can easily forget to consider how the patient feels and thinks.” Many of the activities that care providers experience as commonplace are new to the patient and can be worrisome. How often was this patient updated around timing of her admission? When the IV issue was addressed, did staff take the time to address other concerns or fears that the IV problem evoked? Did staff talk with her about what to expect during the night? How can HHS address issues that may impact patients’ perceptions of care, including issues around safety, clinical care and communication?

Send suggestions to This email address is being protected from spambots. You need JavaScript enabled to view it. . HHS is committed to creating a culture of safety that not only provides exceptional care, but helps patients know they are receiving exceptional care.

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