Quality & Safety

Quality & Safety

Every day, Monument Health physicians and caregivers strive to provide you the kind of care you deserve. High-quality care is our top priority. We have received awards and recognition for quality and safety. Yet we continue to look for ways to improve the processes, protocols and practices that make our hospitals and clinics the safest and most effective healing environments possible.

Our Quality & Safety Principles

1. Patient/ Resident/ Family Centered

This means:

  • Providing care that is easy for patients to get when and where they need it.
  • Making sure that the healthcare team respects and responds to the patient choices, needs and values.
  • Forming partnerships between patients, their family and care team.

2. Decisions are Driven by Information

This means:

  • Using up-to-date knowledge and evidence to guide decisions about care.
  • Safety and quality data are collected, analyzed and used to support improvement activities.

3. Safety at the Core

This means:

  • Making safety a central feature of how Monument Health operates, how the care team works, and how resources are allocated.

Download the Monument Health Safety & Quality Program information sheet.

Monument Health Initiatives

Stroke Process

In fiscal year 2018, Monument Health shortened the average time between arrival at the Emergency Department the administration of Alteplase (clot buster) to 55 minutes. The recommended time is within one hour.

We developed a “pit stop” process, a multidisciplinary team response to “stroke alert” patients, with assessment and care initiated before the patient is placed in a room.

Result: 55-minute average response time.


Monument Health implemented best practices procedures to prevent Central Line Associated Blood Stream Infections (CLABSI) and Clostridium difficile (C. diff).

  • CLABSI – Best practices insertion procedures and best practices in maintenance in dressing change procedures resulted in fewer central line infections.
  • C. diff — Antimicrobal Stewardship, environmental cleaning processes and use of ultraviolet lights resulted in a decrease in C. diff infections. (Monument Health scores better than the national benchmark in this category.)

Result: Monument Health has received national recognition from the Agency for Healthcare Research and Quality (AHRQ) for its decreases in CLABSI and Catheter Associated Urinary Tract Infections (CAUTI).


A disease with life-threatening complications, diabetes affects a large number of western South Dakota residents. To help fight diabetes, we have:

  • Established regional outreach clinics throughout western South Dakota.
  • Standardized case management for care and testing.
  • Introduced Diabetes Champions to help patients with assessment, care and education.
  • Worked closely with inpatients on monitoring and education.
  • Used community and national resources to help patients get medications.

Result: Levels of HbA1c, a key measure of blood sugar over time, have been improving in the region.

Team-Based Care

  • In Custer, we launched a process that allows ambulatory physicians to focus on patient care, rather than documentation.
  • We standardized workflow for patient care.
  • We ensure that all caregivers can use their expertise to collaboratively provide care.
  • We provide timely access to outpatient care.

Continuity of Care

  • We use multidisciplinary rounds to coordinate care.
  • Our physicians serve and coordinate with local skilled nursing homes.