Quality Corner

February Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee [QIPSC],
chaired by Joseph Hopkins, associate chief of staff

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• PATIENT SAFETY DASHBOARD
  
  • Do Not Use Abbreviation compliance at 94 percent
  
  • Universal Protocol at 80 percent compliance in nonsurgical areas
  
  • Medication Reconciliation
  • Nursing compliance improved to 100 percent
  • M.D. compliance continues to increase
• HAND AND HYGIENE ACTION PLAN
  
  • Alcohol gel dispensers placed in all hospital areas
  
  • Unit-based projects focus on hand hygiene
  
  • Unit "champions" acknowledged
  
  • Patient education developed
  
  • SHC employees sign hand hygiene pledge
  
  • Executive Safety Walk Rounds include observation of hand hygiene and discussions with staff on how to improve compliance
  
  • Secret observer ("secret shopper") rounds continue
  
  • Cultural change initiatives
  • Imbed hand hygiene in daily practice
  • Encourage staff members to communicate importance of hand hygiene with each other
• STRATEGIC CLINICAL INITIATIVES PROJECT (SCIP) – Iatrogenic Pneumothorax
  
  • Finding: Main cause of iatrogenic pneumothorax is central venous catheter (CVC) insertion using subclavian method
  
  • Recommendation: Promote ultrasound-guided IJ catheterization as method of choice for CVC
• OR MEDICAL COMMITTEE FINDINGS
  
  • Mark visible after drape – inconsistent compliance in OR and ASC
  • Recommendations
    • ASC – Adjusting breast mark placement has resulted in increase in compliance average of 98 percent
    • Main OR
      
      Surgeons requested to repeat mark after drape
      
      Clarification of site markings in policy has resulted in an increase in compliance to 100 percent for quarter
• • Count Pause compliance for quarter
  • ASC – 99 percent
  • Main OR – 93 percent
    
    • Time out antibiotics given – 99 percent compliance in Jan. ’08