Quality Corner
March Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee [QIPSC],
chaired by Joseph Hopkins, associate chief of staff
- Neurosciences Services
- An unannounced JCAHO stroke survey is expected anytime after April 1- Physicians can anticipate being asked questions from the survey team on the NPSGs [National Patient Safety Goals].
- Physicians who care for stroke patients will be asked questions regarding the patient care goals of the interdisciplinary team.
- Influenza
- Planning is under way to determine dose ordering for 2007 influenza protection.
- 4,825 influenza vaccines were given to staff in October 2005.
- No cases of influenza were reported at SHC in February.
- Rapid Response Team [RRT]
- RRT is operating well.
- The implementation outcomes match other institutions in the same development phase.
- Strategies are slated to identify earlier those patients who could benefit from anticipated RRT evaluation and treatment.
- During the first quarter of ’06, the team fielded 88 calls.
- 70 percent of response request calls to the RRT to prevent critical complications were made by nursing staff. Ten percent were made by M.D.s.
- RRT requests were triggered by a variety of urgent patient care conditions, with respiratory distress from several etiologies being the most common.
- Nosocomial Surveillance
- ICUs —The 2005 annual Infection Control and Epidemiology Surveillance Report focused on:
- Relevant interventions related to venti-
lator care that when implemented
together produce better outcomes
for patients - Central line site care procedures lead-
ing to implementation of Biopatch
- Relevant interventions related to venti-
- Cardiac Surgery — Chlorhexidine-glucomate with alcohol surgical skin prep will be undergoing evaluation in the cardiac surgery service.
- ICUs —The 2005 annual Infection Control and Epidemiology Surveillance Report focused on:
- National Patient Safety Goals Universal
Protocol “Time-Out”
- The main and ambulatory surgery areas are field testing a new marking pen (Xodus Medical, Penn.). The new device pens provide rulered caps, labels, nontoxic/latex marking and other benefits to enhance surgical marking and safety.
