Quality Corner
February Highlights of Performance Improvement at SHC
- Quality Improvement and Patient Safety Committee [QIPSC]
Joseph Hopkins, associate chief of staff, chair
2007 Performance Improvement highest priority projects
— to be monitored quarterly to ensure results
xx• Mortality Review
xx• Core Measures
xx• Antibiotics Prophylaxis
xx• Ventilator Management
xx• Universal Protocol
xx• Diabetes Collaborative
xx• Post-operative Hemorrage/Hematoma
xx• Failure to Rescue
CHART (California Hospital Assessment and Report Taskforce)
— public reporting website
• Hospital data posted March 7 to include new information on:
ICU Process Measures
ICU Mortality and Length of Stay
Hospital Acquired Pressure Ulcers
Maternity
Pediatric
• Other public data will continue to include:
AMI Measures
Heart Failure
CABG
Pneumonia
Surgical Infection
HCAHPS
Leapfrog Group (national comparative data)Core Measures related Task Force Groups have been formed with clearly identified action plans:
• Discharge instructions
• Smoking cessation counseling
• Time to PCI (Percutanous Coronary Intervention) facility NPSG (National Patient Safety Goals)
• "QD" and “QOD” unapproved abbreviations at 83 percent compliance
• NPSG action summary:
HIMS completes chart audits and provides the quality department with list of non- compliant physicians
Quality Department will send out letters to non- compliant physicians
Education toolkit on Universal Protocol to be rolled out to nurses and will be presented at Nursing Quality Council
In cooperation with Materials Management, operating room Boarding Pass forms to be in the same location as procedure trays
“Hand Hygiene Saves Lives” campaign continues
