QUALITY QUARTERLY
QUALITY & INFECTION PREVENTION
ITS THAT TIME AGAIN TO CATCH YOU ALL UP ON QUALITY NEWS. WE HOPE YOU HAVE BEEN ENJOYING THIS NEWSLETTER, ITS BEEN FUN FOR THE QUALITY TEAM TO CREATE!
IN CASE YOU WERE WONDERING WHO IS THE QUALITY TEAM... SEE PICTURE FROM PATIENT SAFETY FAIR. LEFT TO RIGHT, LAVINIA, LINDY, BELLE, DEBRA.
HAPPY READING!
INFECTION PREVENTION
COVID/FLU
IF YOU DID NOT RECIEVE YOUR FLU SHOT DURING SKILLS FAIR AND YOU HAVE INSURANCE, PLEASE SEE PROVIDER OF YOUR CHOICE BY NOVEMBER 1ST.
NO INSURANCE PLEASE SEE HR OR QUALITY FOR VOUCHER TO RECIEVE FLU SHOT IN OUR ED DEPARTMENT BY NOVEMBER 1ST.
HAND HYGIENE
- Unit Percent
- Pre-Op Main: 83%
- Pre-Op South: 92%
- PACU Main: 75%
- PACU South: 91%
- Inpatient: 96%
- Physical Therapy: 89%
- Other: 100%
- HPH: 92%
GREAT CATCH AWARD
SKILLS FAIR
DNV FOR ORTHOPEDIC CENTER OF EXCELLENCE (OCE)
Orthopedic Center of Excellence (OCE) Survey September 27, 28, and 29 has been rescheduled for mid October, we will update accordingly.
DNV Annual Accreditation Survey is announced and the arrival window is Nov1 – Jan 1. They will round on at least 1-night shift.
VARIANCE REPORTING
Feedback on Year to Date Most Common Variances:
Registration Errors: 92 variance entries YTD
Why is this important? The Registration team is doing an amazing job catching many of the identification mis-matches before the patient is admitted, however, if an identifier is mis-matched in a patient care area, this can lead to serious patient harm. This is a complex issue that many departments are working diligently on to keep our processes consistent and our patient’s safe.
Case Cancelations: 18 variances entered YTD
Reviewed for potential prevention opportunities.
ED transfer to higher level of care: 14 variances entered YTD
Reviewed for opportunities to care for the patient at HPH.
Two recent important topics/trends in variance reporting system:
1) Physician’s office wrong patient/laterality issue: These are being caught at the HPH point of entry- (GREAT JOB OCEC), however, we are working with the office to provide data and opportunities for improvement. Please stay hypervigilant on verifying laterality with your patients.
2) PT/INR results unexpectedly high. We are working with a team to identify the root cause and solution.