Quality Corner
January Highlights of Performance Improvement at SHC Quality Improvement and Patient Safety Committee [QIPSC]
Joseph Hopkins, associate chief of staff, chair
JCAHO has notified SHC of areas it will focus on during its 2006 survey
• Priority Focus Areas — JCAHO identifies each year processes, systems, or structures within a healthcare organization known to significantly impact the safety and quality of care. The four PFAs that JCAHO has selected for Stanford are:
- 
Staffing
- Credentialed practitioners
- Quality improvement expertise/activities
- Communications
• JCAHO also identifies Clinical Service Groups that will be a focus during the survey. The principal patient care areas from which cases will be reviewed during the survey are:
- Cardiology
- Pulmonary
- General surgery
- General medicine
Code Blue Committee Report — new defibrillators ordered
• Total number of cardiac arrest code calls for 2005 is comparable to the prior year
• Acute respiratory insufficiency represents 69 percent of medical emergency calls
• The committee identified high incidence of bradycardia as the initial rhythm associated with cardiopulmonary arrest at SHC
• Changing defibrillators indicates an opportunity to provide earlier advanced life support. Advantages of replacements:
- New defibrillators will be biphasic with capability of AED (Automatic External Defibrillation), pacing, and cardioversion/defibrillation
- Allow early defibrillation by non-critical care nurses
- Lower energy delivery due to biphasic technology
- Standardization to one device
The Human Resources Department reported that the turnover rate for employees at the end of the last fiscal year is 11.1 percent, well below the 20 percent national healthcare average. Labor continuity benefits caregivers and contributes to operational efficiency. Also, SHC increased its college recruitment to 40 colleges to ensure adequate staffing in a tight employment market.
