Hospital Safe Practices: Surgical Site Infection Prevention, Hand Hygiene, and Central Venous Catheter Related Bloodstream Infection Prevention

The following questions come from the Leapfrog Group’s Hospital Quality and Safety Survey.

The Leapfrog Group consists of many large private and public organizations that provide health benefits for more than 34 million U.S. employees, retirees and dependents. The Group’s goal is to improve health care safety.

The Quality and Safety Survey is based on 30 hospital “safe practices” that were identified by the National Quality Forum. Here is how the hospital responded to the questions on three of those safe practices -- Hand Hygiene, Surgical Site Infection Prevention, and Central Venous Catheter Related Bloodstream Infection Prevention:

Safe Practice – Hand Hygiene
In regard [to] nosocomial infections related to inadequate hand washing, our organization is:

Aware of our performance improvement opportunity in this area in that
X_ We have undertaken an enterprise-wide educational effort addressing the frequency and severity of nosocomial infections within our patient population and potential impact of performance improvement practices related to the absence of or inadequate hand washing, within the 12 months prior to submitting this survey, as documented by meeting minutes, attendance or completion records.

Within the last 12 months prior to submitting this survey, the organization has:
X_ performed an enterprise-wide evaluation of the frequency and severity of nosocomial infections.
X_ submitted a summary report to administration and governance with recommendations for measurable improvement targets and further action.

In the next 12 months our organization plans to conduct ongoing evaluation, monitoring and report recommended measurable improvement targets related to this area to administration and governance.

Accountable to this issue as evidenced
X_ by departmental/clinical service line managers all being directly accountable for the patient safety area through documented personal performance reviews or personal compensation incentives, or other organization-specific documented evaluation review processes.
X_ by having developed documented personal performance reviews or personal compensation plans, or other organization-specific documented evaluation review processes which now hold senior executives in addition to department/clinical service line managers accountable for this safe practice.
X_ the organization has either a Patient Safety Officer or an Administrator who oversees organizational patient safety regularly reporting to the CEO and the Board performance improvement metrics related to this safe practice and is directly accountable for this through documented personal performance reviews or compensation, or other organization-specific documented evaluation review processes.

Invested in our ability to deal with this issue by
X_ Within the last 12 months prior to submitting this survey, conducting staff education/knowledge transfer and skill development programs as documented by meeting minutes, attendance or completion records.

Our organization will investigate ways to: document expenditures on staff education related to this safe practice in the coming year and incorporate additional funding in the new budget.

Taking additional actions to ensure that
X_ explicit organizational policies and procedures are in place across the entire enterprise to prevent nosocomial infections due to inadequate hand washing techniques including CDC guidelines with category IA, IB, or IC evidence with routine measurement of compliance and process improvement addressing compliance within the 12 months prior to submitting this survey.
X_ by having implemented a formal performance improvement program addressing nosocomial infections (with regular performance measurement and tracking improvement within the last 12 months) focused on hand washing techniques and compliance.
X_ by having implemented an enterprise-wide performance improvement program for hand washing compliance (with regular monitoring and measurement of indicators within the last 12 months).

Our organization will complete, in the next 12 months, a formal, enterprise wide performance improvement program addressing all elements of this Safe Practice and Additional Specifications with ongoing monitoring and measurement and subsequent process improvement based on established targets.

Safe Practice – Surgical Site Infection Prevention
In regard to surgical site infections, our organization is:
Aware of OUR performance improvement opportunity by
X_ undertaking an evaluation of the frequency, severity, and potential impact of performance improvement practices on surgical site infections in our patient population within 12 months prior to submitting this survey.
Within the last 12 months prior to submitting this survey, the organization has:
X_performed an enterprise-wide evaluation of the frequency and severity of incidents of surgical site infections.
X_ completed a literature review to determine best practices.
X_ has submitted a summary report to administration and governance with recommendations for measurable improvement targets and further action.
For the last 12 months or more,
X_ the organization, through ongoing evaluation, has monitored and continues to report results of measurable improvement targets related to this area to administration and governance.

Accountable to this issue as evidenced by
_ our senior executives and departmental/clinical service line managers all being held directly accountable for performance in this patient safety area through documented personal performance reviews or personal compensation incentives, or other organization-specific documented evaluation review processes.

X_ our organization has either a Patient Safety Officer or an Administrator who oversees organizational patient safety regularly reporting to the CEO and the Board performance improvement metrics related to this safe practice and is directly accountable for this area through documented personal performance reviews or compensation, or other organization-specific documented evaluation review processes.

Invested in our ability to deal with this issue by
X_ Conducting staff education/knowledge transfer and skill development programs as documented by meeting minutes, attendance or completion records during the 12 months prior to submitting this survey.

The organization:
X_ allocated compensated staff time to work on this safe practice.
Our organization will investigate ways to: document expenses incurred in the coming year tied to this safe practice and incorporate additional funding in the new budget.

Taking action to address this issue by having already actively implemented explicit polices and procedures for documented risk assessment and prevention plans for reducing surgical site infections including:
X_ appropriate use of antibiotics
X_ appropriate hair removal
_ postoperative glucose control
X_ postoperative normothermia
By having implemented a formal performance improvement project/program (with regular performance measurement and tracking improvement within the last 12 months) addressing reduction in surgical site infections and implementation of specific protocols as documented in the medical record including:
X_ appropriate use of antibiotics
X_ appropriate hair removal
X_ postoperative glucose control
X_ postoperative normothermia

X_ by having implemented a clinical unit-wide, department-wide, or service line performance improvement process (with regular monitoring and measurement of indicators within the last 12 months) specific to surgical site infection prevention.

Our organization will complete in the next 12 months, a formal performance improvement program including all surgical patients addressing all elements of this Safe Practice and Additional Specifications with ongoing monitoring and measurement and subsequent process improvement based on established targets.

Safe Practice – Central Venous Catheter Related Bloodstream Infection Prevention
In regard to central venous catheter-related infections, our organization is:
Aware of OUR performance improvement opportunity
X_ having undertaken an evaluation of the frequency, severity, and potential impact of performance improvement practices on central venous catheter related blood stream infections in our patient population within the 12 months prior to submitting the survey.
Within in the last 12 months prior to submitting this survey, having:
X_ performed an enterprise-wide evaluation of the frequency and severity of incidents of central venous line infections.
X_ completed a literature review to determine best practices.
X_ submitted a summary report to administration and governance with recommendations for measurable improvement targets and further action.
For the last 12 months or more,
X_ the organization, through ongoing evaluation, has monitored and continues to report results of measurable improvement targets related to this area to administration and governance.

Accountable to this issue as evidenced by
_ our senior executives and departmental/clinical service line managers being directly accountable for the performance in reducing central venous line infections through documented personal performance reviews or personal compensation incentives, or other organization-specific documented evaluation review processes.

X_ the organization has either a Patient Safety Officer or an Administrator who oversees organizational patient safety regularly reporting to the CEO and the Board performance improvement metrics related to this safe practice and is directly accountable for this area through documented personal performance reviews or compensation, or other organization-specific documented evaluation review processes.

Invested in our ability to reduce the impact of central venous line infections by
X_ conducting staff education/knowledge transfer and skill development programs as documented by meeting minutes, attendance or completion records during the 12 months prior to submitting this survey.
Our organization will investigate ways to: allocate compensated staff time to work on this safe practice, document expenses incurred in the coming year tied to this safe practice and incorporate additional funding in the new budget.

Taking actions to address central venous catheter infections
X_ by having actively implemented explicit organizational policies and procedures that includes appropriate adult or pediatric specific bundle elements to prevent the occurrence of catheter-related infections.
X_ by having implemented a formal performance improvement program (with regular performance measurement and tracking improvement within the last 12 months) addressing central venous catheter-associated blood stream infections and compliance with prevention strategies.
X_ by having implemented a clinical unit-wide, department-wide, or service line performance improvement process (with regular monitoring and measurement of indicators within the last 12 months) specific to central venous catheter-associated blood stream infection prevention.

Our organization will complete, in the next 12 months, a formal, performance improvement program that includes all patients with central venous catheters addressing all elements of this Safe Practice and Additional Specifications with ongoing monitoring and measurement and subsequent process improvement based on established targets.

Glossary of Terms
Central Venous Catheter: A flexible tube that is inserted into one of the large veins or arteries. A central venous catheter can be use to give fluids, measure the amount of fluid in the body or give medications.
Nosocomial Infection: A localized or systemic condition 1) that results from adverse reaction to the presence of an infectious agent(s) or its toxins and 2) that was not present or incubating at the time of admission to the hospital. (Source: Centers for Disease Control and Prevention)