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Quality & Safety

Our focus at UNC Health Rockingham is to deliver safe, high-quality care and outstanding service to every single patient. We have a strong commitment to include our patients and their families in decision making, along with our doctors, nurses and other health care professionals. We are proud of our colleagues and the work they do each day to create a culture of patient safety and quality improvement. We are a nonprofit, 108-bed community hospital preserving excellent, compassionate and trusted care.

We invite you to learn more about some of the work we do every day.


Falls can occur in any type of health care institution and to any type of patient. Changes in the patient’s health status, responses to medication, treatments or anesthesia, as well as being in unfamiliar surroundings are some of the leading causes for patient falls. At UNC Health Rockingham, we endeavor to prevent falls in the hospital setting. Many new initiatives have begun at UNC Health Rockingham to decrease falls in our facility including reinforcing to our patients that they should call for assistance.

Our fall rate has remained about the same from 2021 to 2022.

Clean In, Clean Out

Adherence to strict hand hygiene practices is extremely important to the health and safety of our patients. When healthcare employees properly wash their hands, we decrease the chance of our patients acquiring an infection while they are in our care. This saves lives! We use the Clean In, Clean Out program which sets expectations that all employees wash their hands or hand sanitize every time they enter and exit a patient room and also monitors compliance. The hand hygiene goal applies to both clinical and non-clinical staff members because we all keep our patients safe by practicing proper hand hygiene.\

For the current Fiscal Year, 2021/2022, UNC Rockingham has maintained a compliance rate greater than 90 percent, all while caring for a greater number of patients.


To reduce readmissions within 30 days of discharge, all unplanned readmissions are tracked. We have achieved a significant reduction in our overall 30-day readmission rate by implementing standard practice for patients at risk for readmission. We ensure that, upon discharge, our patients understand medication, dietary restrictions, physical activity limitations, follow-up care and follow-up appointments. Our readmission rates are low compared to national benchmarks, and UNC Health Rockingham has one of the lowest readmission rates in the UNC Health system.

Emergency Department Length of Stay

The time spent waiting for and receiving care in an Emergency is an indicator of operational efficiency, but is often difficult to predict. We recognize that the primary reason for seeking care in the Emergency Department is to see a provider, and our goal is to make that happen as promptly as possible. Initiatives have been put in place to improve the process. During peak times, a clinician is placed in the entry area and a provider in Triage (the area where a patient is evaluated to determine the urgency level). Using a direct bedding approach, some patients are assigned immediately to available beds in the Emergency Department, bypassing Triage. Since January 2022, our Emergency Department has improved the average overall length of an Emergency Department visit (Length of Stay) from 242 minutes to 171 minutes. From a patient’s arrival time in the waiting area, to the point when a patient speaks to a member of our staff has reduced from 40 minutes in January 2022 to currently an average wait time of 17 minutes.

Healthcare Associated Infections

Our staff work hard to keep patients as safe and healthy as possible while they are in our care. Unfortunately, the procedures and treatments necessary for care also increase the risk for infection. Inserting a urinary catheter, IV line or being on a ventilator are some of the very necessary procedures that present greater risks for infection. To help us decrease these risks, we follow published best-practice guidelines to ensure that devices such as urinary catheters, IVs and ventilators are used only when necessary. We do everything possible to remove them as soon as they are no longer necessary. If a patient has surgery, we follow best-practice guidelines to reduce the chance of a post-surgical infection. When combined with our “Clean In, Clean Out” program, we are doing everything we can to keep our patients’ safe. During the 2021/2022 Fiscal Year, at a time when many hospitals saw significant increases in hospital acquired infections, we have maintained rates below the national benchmark for CAUTI, CLABSI, and SSIs, some of the most common hospital acquired infections.