Quality Corner
November Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee [QIPSC],
chaired by Joseph Hopkins, associate chief of staff
"Red cape" coordinator enhances
education/compliance in key safety areas
- An RN "red cape" coordinator has
successfully enhanced core measures
benchmark scores in three key areas:
- Pneumococcal vaccine — 80 percent compliance
- ASA at discharge — 100 percent compliance
- Antibiotic selection for CAP — 75 percent compliance
- The "red cape" coordinator was designated in pilot studies to collaborate with nurses, physicians and other clinical staff to improve quality measures by enhancing documentation, augmenting patient education and alerting clinicians to national health care standards for select groups of patients
- Kevin Tabb, chief quality officer, emphasized that the measures are being compared locally and nationally and that results are being released under enhanced public scrutiny
-
Other interventions to enhance core measures are under way
National Patient Safety Goals compliance
- Unapproved abbreviations
- SHC is continuing to meet compliance
goals and is focusing on three specific
abbreviations:
– "cc"
– "QD"
– "SQ" - The pharmacy is collecting the use of these abbreviations and is transmitting provider-specific reports to the Medical Staff Office, Graduate Medical Education Office, Patient Care Services and chiefs of service so that appropriate counseling can be done with specific providers
- SHC is continuing to meet compliance
goals and is focusing on three specific
abbreviations:
-
Wrong site surgeries
- Audits continue to show that SHC is meeting compliance targets for this goal. Efforts are being focused on the requirements for:
– "Surgery site mark visible after drape"
– "Consent and Schedule ‘OK'" - Operating Room Medical Director Richard Whyte is following up on these areas and will clarify requirements
-
(A third flagged item, "H&P complete, timely and on chart when patient interviewed," will be removed from the audit because all cases proceeding to the OR were compliant
"Dashboard" Core measures
Current initiatives designed to prevent potential errors include new IV pumps, EMD, bar coding and medication reconciliation - Audits continue to show that SHC is meeting compliance targets for this goal. Efforts are being focused on the requirements for:
