Quality Corner
June Highlights of Performance Improvement at SHC
- Quality Improvement and Patient Safety Committee [QIPSC]
Joseph Hopkins, associate chief of staff, chair
DVT/P
-- Newly revised DVT/PE risk assessment form was implemented in the OR region effective June 5 - See article in June ’06 Medical Staff Update on page 6 or http://med.stanford.edu/shc/update/dvt.htm
• Daily monitoring and feedback to physicians and nurses has resulted in significant compliance improvement
• Quality specialist to continue with weekly reporting to leadership to ensure progress towards identified targets
Preoperative beta blockade
-- Implement standardized approach to prophylactic beta blockade in all patients at risk
National Patient Safety Goals
• Result audits reported monthly to medical staff and medical center leadership committees and focused action plans are required to ensure best practices
• Education continues - To improve house staff compliance with NPSG, a comprehensive quality orientation packet was included in new house staff orientation
Iatrogenic Pneumothorax
• Hospitalists and attendings to supervise residents performing invasive procedures
• Simulation Unit to open in fall to train housestaff and nursing staff
• Ultrasound required for IJ central line insertions
Point of Care Testing (POCT) Policy Changes
• Infection control policy applies to POCT
• Self-testing prohibited - physician order required for POCT
• Guideline added for utilization of iSTAT HCT parameter
• Policy added to address patient home glucose meter us
• New tests: lactate, GFR, troponin and creatinine
Medication Reconciliation
-- policy revised to include:
• SHC outpatient services - clinics
• Emergency Department
• 23-hour unit
