Quality Corner

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

• Joint Commission Summary presented— [see chief of staff column]

• Ever Ready (continuous vigilance) Dashboard
  
  • Universal Protocol compliance on medical/surgical units has increased to 100 percent.
  • Hand Hygiene Protocol compliance has improved to 93 percent
  • Medication Reconciliation compliance has decreased to 80 percent

• Quality Dashboard— UHC benchmarks improved from 2005 to 2006

  • Mortality Rates (new UHC mortality applied)
  Surgical mortality improved by 11 points
  x Medical mortality improved by 20 points

  • Core Measure Score improvements:
  AMI – 25 points
  x PNA – 42 points
  x HF –11 points

  • Core Measure Composite Score:

10 Measure Score – achieved 85 percent – goal 90 percent
x 21 Measure Score – achieved 65 percent – goal 90 percent

• CHART first quarter ’07

HOB elevation

-Compliance significantly improved to 79.3 percent per observation
x (CHART 2006 – 93.6 percent)

-24 percent improvement in compliance after the first observation

-27.8 percent improvement in compliance after the second observation

-67.6 percent compliance at both observations (CHART 2006 – 89 percent

DVT prophylaxis improved to 100 percent compliance from 98 percent (CHART 2006 – 96.3 percent)
Peptic ulcer disease prophylaxis decreased to 94 percent from 100 percent (CHART 2006 – 99.4 percent)

• Communication— Based on guidance and leadership from Working Group on Quality, a newsletter, Quality Alert, has been developed to enhance communication among healthcare providers about outcomes data and safety concerns
• Needle sticks safety improvement— Sharps Safety Task Force proposed system wide (96 percent) implementation of BD array of needles and syringes with a provision for use for special circumstances. Program to be implemented immediately after one-month trial.
• Organ donation— SHC Conversion rate is 80 percent, better than the national goal of 75 percent.
• Insulin Protocol

• Components of a pilot project on E1 explored whether a multi-pronged approach could improve clinical practice and reduce hyperglycemia using the following elements:

Early identification and monitoring
Appropriate insulin therapy
Education and documentation

• Recommendations
Eliminate Insulin Sliding Scale effective February 2008
x Insulin Protocol will be rolled out to the medical service,
then the surgical service, by February 2008
Request for additional staff to provide diabetes patient education