Quality Corner
October Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee [QIPSC],
chaired by Joseph Hopkins, associate chief of staff
- Organ Donor Conversion Rate (eligible vs. total donors) of 81 percent exceeds national goal of 75 percent
• Number of referrals during third quarter – 156
• Hospital referral compliance – 98 percent
• Organs per donor – 3.76 – exceeds national goal of 3.75 -
Hand hygiene compliance audit by “secret shopper”
• Attending MDs: 71 percent
• House staff: 44 percent
• Task force working on hand hygiene (washing) compliance -
Core Measure — 24 metrics composite score improved from 55 percent in Oct. 2006 to 85 percent in Aug. 2007
-
VTE Prevention - Medicine
• Inappropriate prophylaxis reduced from 75 percent in 2002-03 to 22 percent in the last six months of 2006
• Medicine Department solutions produced improvement
Education/card for risk assessment of prophylaxis
CareCast order set implemented for VTE prophylaxis
in June 2007
• Recommendation – duplicate successful process in Epic -
Mortality rate for ventilated patients in E2 ICU reduced from 47 percent in February 2007 to 9 percent in September 2007
-
MRSA rates rise — changes in procedures
• Place all patients colonized or infected with MRSA on contact precautions
• Contact precautions and signage will be updated to include gowning and gloving by personnel entering patient rooms
• Implement hand hygiene campaign
• Standardize line insertion kits to include large drape -
Moderate Sedation reflects strong upward trend in compliance
• All procedures – 96 percent
• Pre-procedure compliance – 95 percent
• Intra-procedure – 97 percent
• Post-procedure – 96 percent -
Palliative Care (see Nov. Medical Staff Update article: http://med.stanford.edu/shc/update/archives/NOV2007/
pall_care.htm• Consults totaled 94 in first two months of program (Aug. and Sept.) vs. original estimate of 35 consults per month
• Referrals increasing from multiple services
• 66 percent of consults have been discharged out of hospital
• Length of stay for patients more than nine days on ventilator in North ICU reduced from average of 25 days to 15 days after palliative care discussion incorporated in interdisciplinary rounds
