Quality Corner

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

• Joint Commission: SHC is fully accredited for 36 months effective May 25, 2007
• National Patient Safety Goals: compliance
  
  • Do Not Use Abbreviations: improved to 95 percent
  • Universal Protocol: improved in ED to 80 percent
  • Hand hygiene by inpatient staff
  
  Exiting room: 58 percent
  Entering room: 35 percent
  
  • Medication Reconciliation
  
  Form in chart: 96 percent
  Meds recorded by nursing staff remains low: 71 percent
  MD reconciliation
  
  — Admission: 59 percent
  — Discharge: consistent at 83 percent

• National Patient Safety Goals:
  Recommendations — hand hygiene
  
  • Focused interventions leading to action plans to be developed for individual areas
  • Executive reinforcement: hand hygiene pledge
  • Observation: Executive Safety Walk Rounds to focus
  on hand hygiene
  • Information campaign (posters, screen savers, etc.)
  • Targeted feedback: unit specific reports

• Committee priorities identified for 2008
  
  • “Ever ready” dashboard
  • AHRQ (Agency for Healthcare Research and Quality) evidence-based practice programs
  • Core Measures
  • Strategic clinical initiatives
  • Choose and develop key quarterly quality reports
  based on regulatory requirements and identified performance improvement opportunities at SHC