Holy Cross Hospital has reported recent improvements in patient experience measures and sepsis care outcomes, according to internal quality data and hospital leadership. The results reflect changes in monitoring practices, clinical workflows, and coordination across departments, with a focus on patient feedback and early clinical intervention.
Patient Experience Results
Patient experience is commonly used as an indicator of healthcare quality, and Holy Cross Hospital monitors patient satisfaction data on a monthly basis. According to Misty Carruth, Director of Quality, Risk & Compliance, these results are shared regularly with the hospital’s Board of Directors and used by service lines to assess performance and identify areas for improvement.
The hospital tracks ten inpatient experience measures, including communication with nurses, staff responsiveness, communication about medications, cleanliness, quietness, discharge understanding, care coordination, overall hospital rating, and likelihood to recommend the hospital. Each measure is reviewed month over month and compared with state benchmarks.
Hospital data showed improvement across all ten metrics in both September and October, with scores also exceeding state benchmarks during those months. While sustained month-over-month improvement can be difficult to achieve, hospital leaders reported that gains continued into October.
“These results give us useful insight into what patients are experiencing and where changes are making a difference,” Carruth said. “Patient feedback gives us a clearer picture of how care is delivered across the hospital, from admission through discharge.”
Patient satisfaction surveys are distributed to all inpatients following discharge, either by email or mail, and are managed by a third-party vendor to maintain patient privacy. Responses are anonymous unless patients choose to share their contact information. When concerns are identified and contact information is provided, Patient Advocate Nikki Lamendola follows up with patients to better understand their experience. Feedback is then shared with relevant department leaders to develop response plans and better meet the needs of patients.
Carruth noted that collecting patient feedback can be challenging, particularly in hospital settings where patients are often experiencing stress or illness.
“When someone comes to the hospital, it’s often during a difficult moment,” Carruth said. “Hearing directly from patients helps us understand what matters most to them and where we can make care more supportive.”
She added that feedback trends over the past two years show a strong reduction in negative responses, suggesting that process changes are contributing to improved patient experiences.
Sepsis Response Outcomes
Holy Cross Hospital has also reported progress in the early identification and treatment of sepsis, a condition that remains a leading cause of hospital mortality nationwide. Because sepsis often presents in the Emergency Department, early recognition and timely treatment are considered critical to patient outcomes.
Following a reported 44.7 percent increase in sepsis incidence between 2022 and 2023, the hospital formed a multidisciplinary Sepsis Committee in February 2024. The group included representatives from nursing leadership, quality, pharmacy, laboratory services, infection prevention, physicians, and executive leadership. The committee’s efforts, together with methods from the Centers for Medicare and Medicaid Services’ Severe Sepsis and Septic Shock Early Management Bundle (SEP-1), have contributed to the success of this project.
Initiatives included the standardized screening protocols, expanded use of electronic health record automation, lactic acid reflex testing, and targeted staff education. Quick-reference tools known as “Sepsis Badge Buddies” were also introduced and incorporated into staff onboarding.
According to hospital data, sepsis care compliance improved following implementation. In the first three quarters of 2025, the hospital reported only one SEP-1 fall-out, defined as an eligible sepsis case that did not meet SEP-1 measure criteria because sepsis was not identified within the early diagnostic time frame specified by the measure. In 2024, Holy Cross saw a fall-out rate of just over 10 percent, compared with state averages of 40 to 50 percent and national averages of 30 to 40 percent, according to a Holy Cross report. These results led to recognition from the New Mexico Hospital Association.
“Sepsis can be difficult to detect, and early signs are not always obvious,” said Pam Burton, Director of Infection Prevention. “Standardizing processes and improving communication helps teams respond quickly and improves outcomes.”
Hospital leaders said the results reflect a broader commitment to continuous improvement, teamwork, and patient-centered care across the organization. Together, the gains in patient experience and sepsis outcomes highlight the impact of coordinated efforts and a shared focus on quality.
“The improvements we are seeing in patient experience and sepsis outcomes represent a significant accomplishment for our team,” said James Kiser, CEO of Holy Cross Medical Center. “People from across the hospital come together every day to provide excellent care, and just as importantly, to keep finding ways to make that care even better. The dedication, collaboration, and commitment to improvement shown by this team are exceptional, and it is something truly special to have this level of care available right here in Taos.”