Recent
Highlights, Compiled in June, of Performance Improvement at SHC
-From the SHC Quality Improvement and Patient Safety Department, Joseph
Hopkins, associate chief of staff, chairs the Quality Improvement and
Safety Committee.
Allograft
Protocol
--The Infection Control Committee and the OR Medical Committee have
approved Allograft Tissue Criteria standards for vendors outlining the
process and procedures vendors must follow when supplying bone, tissues,
and skin allografts to the Medical Center.
SHC
has established areas outside the hospital where the hospital will be
responsible for providing a response team for emergencies.
Culture
of Safety
--Programs to educate and promote safety include rounds by hospital
executives, a monthly employee safety award program and a successful
and a widely attended hospital Safety Fair in March. Seventeen "Safety
Star Awards" have been presented to staff members who have made especially
useful suggestions for improvement.
Radiology
Reads Project Improvement Update:
Reporting and documentation of reports to physicians for preliminary
"reads" have been discussed with involved departments and suggested
improvements have been made. Physicians will continue to be called when
there is a change in a final reading.
A system which will allow physicians and other caregivers to view preliminary
readings electronically should be available to physicians through PACS
in the fall.
The
hospital continues to closely compare its performance against University
Hospital Consortium Benchmarks on a variety of clinical indicators.
Quality improvement teams are creating improvements for many of these
clinical conditions.
Physicians
are reminded to ensure that site of surgery marks are visible after
draping.
Surveys
show improvement in patient service - including a decrease in waiting
times for new patient appointments - at the Cancer Center, which opened
in March.
Steps
to monitor pathology specimen handling in operating rooms are being
monitored as part of a procedural upgrade.
Requests
for non-formulary medications range from 2 to 12 per month.
Full
compliance was achieved in securing and maintaining ECT patient consent
forms during April and May.
Twenty-one
additional security officers have been hired as part of a general security
upgrade.
Patient
satisfaction with hospital food service is improving with greater menu
choices and enhanced courtesy of servers.
Physicians
continue to be the most common group of people experiencing sharps injuries
in the hospital - 31 percent more common than nurses. Physicians should
increase their awareness of handling of sutures and local anesthesia.
Patients'
satisfaction with their physical comfort in the hospital (pain management,
etc), continues to improve.
Physicians
are reminded to NOT use the following abbreviations: "qd" and "cc" because
these are subject to higher rates of misinterpretation. Instead use
"daily" and "ml". Physician orders and progress notes will be audited
to monitor unapproved abbreviations.
Physicians
are strongly urged to use the Patient Safety Net system on all hospital
work stations to report any concerns about patient management. Currently,
71 percent of this data comes from nurses, only 1.4 percent from house
staff, and 0.6 percent from attending MDs.
