Post on 02-Jan-2016
transcript
Infection Prevention Quality Plans
QI Showcase - April 13, 2011
Barbara Dumont, RN, CPHRMSt. John’s Lutheran Hospital
Libby, Montana
Challenge How could we raise awareness hospitalwide
to improve our safety culture and infection prevention practices?
Our Quality Committee decided to choose Infection Prevention as our global goal and all departments were expected to address this in their quality plans for FY2011.
Quality Plans Each clinical and
non-clinical department met the challenge and developed infection prevention goals.
Pig PenDietary posted the
Pig Pen picture and
pointed to it when
staff did not do a 20
second hand wash
– they used a timer
Flu Vaccine:Seasonal influenza
vaccine compliance
to include either
receiving the
vaccine or signing
the declination
form
Personal Protective Equipment Staff received education
on PPE or reviewed where to find PPE and when to use it.
Staff were observed for using PPE properly.
Plant ops monitored their staff wearing gowns when entering the surgery area.
Central IV Lines Our CL policy had
been revised the previous year, which included changing from alcohol prep to ChloraPrep.
New hub caps were purchased that have 70% isopropyl alcohol (IPA) in them to decrease infection at the hub.
Equipment Sanitizing Imaging sanitized
exam rooms MM developed a policy
to decontaminate devices prior to inspection, service or repair
Use of blood pressure cuff disposable covers
Environmental Cleaning EVS monitored
cleaning using a marker pen and blacklight.
Office staff sanitized doorknobs when someone entered who had a cold.
Education
Infection prevention
education is included
in our annual
employee safety
education through
Healthstream online.
Outcomes Hand Hygiene goals 90-100% Overall = 89%
compliance (ranged from 68%-100%)
Flu Vaccine: 87% compliance with
staff receiving vaccine. 100% overall with either receiving vaccine or signing declination form.
Outcomes continued…. Personal protective
equipment
Thresholds 85-100% Central IV line infection
rate
Threshold < 5% Equipment sanitizing
Thresholds 90-100%
97% compliance
2.94%
91% compliance
Outcomes continued…. 2010: IP staff
education using an all day safety training format
Threshold 100% 2011: IP Healthstream
online education
Threshold 100% by June 30, 2011
Attendance 100%
Currently at 68% completion rate with 2 ½ months to go
FY 2012 Hospitalwide Quality Goal
Each department will develop a unit specific LEAN or similar type project
Sample of topics chosen so far:1. EVS: Patient discharge process2. Pharmacy/Nursing: Medication reconciliation3. Dietary: Wasted meals of discharged
patients