Quality Corner
May Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee [QIPSC],
chaired by Joseph Hopkins, associate chief of staff
- Blood Utilization Policy
— Transfusion Service will now accept type and cross for 28 days prior to each surgery
- Key Quality Indicators
— Task Force initiated to scrutinize and analyze patient fall data and develop action plans to reduce risk and incidents of falls
Quality metrics
• To enhance compliance with medication reconciliation: a refresher course will be provided for hospital staff
• To enhance universal protocol: medical-surgical units will coordinate with Materials Management to have Boarding Pass forms available in the same location as procedure trays
• To enhance compliance with unapproved abbreviations: Health Information Management will continue to send letters to non-compliant physicians with reports to the Medical Staff Office
• In spite of a 30 percent increase in work volume, the coding and scanning of Medical Records continues to meet a Turn Around Time (TAT) of two days
• Chart Completion Delinquency rates greatly improved to 27 percent
— Legibility/clarity issues most commonly identified include unclear addressograph/patient name and unapproved abbreviations sent back to source for clarification
• A joint LPCH and SHC proactive risk management activity to evaluate the preparedness status for various emergency events
• Initial project will use “unannounced mock clinical events” to facilitate caregivers’ recognition of hemorrhage
