Hospital
Safe Practices: Surgical Site Infection and Hand
Washing
The following questions come from the Leapfrog
Group’s Hospital Quality and Safety Survey.
The Leapfrog Group consists of nearly 200 large
private and public organizations that provide
health benefits for more than 39 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 two of those safe practices -- Hand Washing
and Surgical Site Infection:
Safe Practice: Surgical
Site Infection Prevention
Evaluate each pre-operative patient in light
of his or her planned surgical procedure for the
risk of surgical site infection (SSI), and implement
appropriate antibiotic prophylaxis and other preventive
measures based on that evaluation.
Safety Objective: Prevent
person-to-person transmission of infections.
| In regard to surgical site infections,
our organization is: |
| X |
Aware of OUR performance
improvement opportunity by undertaking an
evaluation of the frequency, severity, and
potential impact of performance improvement
practices on surgical site infections in
our patient population within the 12 months
prior to submitting this survey,
OR
the organization has performed an enterprise-wide
evaluation of the frequency and severity
of incidents of surgical site infections
AND completed a literature review to determine
best practices AND has submitted a summary
report with performance improvement recommendations
to Administration for further action.
OR
the organization commits to undertake a
thorough literature review and comprehensive
enterprise-wide evaluation of the frequency,
severity, and potential impact of performance
improvement practices on surgical site infections
in our patient population with a report
to administration within six months of submitting
this survey.
|
| X |
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 personal performance
reviews or personal compensation incentives,
OR
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.
OR
our organization commits to having our
Patient Safety Officer regularly report
to the CEO and Board of Directors (or sub-committee
of the board) pertinent performance metrics
associated with the reduction of surgical
site infections within six months of submitting
this survey.
|
| X |
Invested in our ability
to deal with this issue by conducting staff
education/knowledge transfer and skill development
programs as documented by meeting minutes
and attendance records during the 12 months
prior to submitting this survey,
OR
the organization provided compensated staff
time to develop standardized protocols to
reduce the risk of surgical site infections
and there is documentation in patient medical
records of implementation of these protocols.
OR
commits to invest allocated compensated
caregiver staff time to develop a standard
protocol including specific risk reduction
interventions (e.g., use of prophylactic
IV antibiotics) and documentation of implementation
of the protocols in the medical records
of surgical patients within six months of
submitting this survey. |
Safe Practice: Hand Washing
Decontaminate hands with either a hygienic hand
rub or by washing with a disinfectant soap prior
to and after direct contact with the patient or
objects immediately around the patient.
Safety Objective: Prevent person-to-person
transmission of infections.
| In regard to nosocomial infections
related to inadequate hand washing, our organization
is: |
| X |
Aware of OUR performance
improvement opportunity in this area in
that . . .
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 and attendance
records,
OR
the organization has performed an enterprise-wide
evaluation of the frequency and severity
of nosocomial infections AND a summary report
with performance improvement recommendations
has been submitted to Administration for
further action.
OR
the organization commits to undertake a
thorough literature review and comprehensive
enterprise-wide evaluation of the frequency
and severity of nosocomial infections related
to the inadequate hand washing. A report
with a summary of the readily available
improvement opportunities and recommendations
in this area will be provided to administration
within six months of submitting this survey.
|
| X |
Accountable to this
issue as evidenced . . .
by departmental/clinical service line managers
all being directly accountable for the patient
safety area through personal performance
reviews or personal compensation incentives,
OR
by having developed personal performance
reviews or personal compensation plans which
now hold senior executives in addition to
department/clinical service line managers
accountable for this safe practice.
OR
by our organization committing to assign
accountability to our senior executives
and departmental/clinical service line managers
for this safety patient safety area through
personal performance reviews or personal
compensation incentives within six months
of submitting this survey. |
| X |
Invested in our ability
to deal with this issue by conducting staff
education/knowledge transfer and skill development
programs as documented by meeting minutes
and attendance records,
OR
our organization has documented expenditures
on staff education related to this safe
practice in the previous year and has incorporated
additional funding in the new budget.
OR
our organization commits to make an explicit
dedicated line item budget allocation for
regular in-service educational programs
within six months of submitting this survey.
|
| X |
Taking additional actions
to ensure that explicit organizational policies
and procedures are in place across the entire
enterprise to prevent nosocomial infections
due to inadequate hand washing techniques
with routine measurement of compliance and
process improvement addressing adherence
to policies and procedures within the 12
months prior to submitting this survey,
OR
by having implemented a formal performance
improvement project/program addressing nosocomial
infections (with regular performance measurement
and process improvement within the last
12 months) including hand washing techniques
and compliance,
OR
by having implemented an enterprise-wide
performance improvement process for hand
washing compliance with regular monitoring
and measurement of indicators AND having
implemented specific policies and procedures
for this safe practice.
OR
by making the commitment to undertake a
formal enterprise-wide performance improvement
project/program addressing nosocomial infections
that includes hand washing techniques and
compliance (with regular performance measurement
and process improvement) and implementing
explicit organizational polices and procedures
within six months of submitting this survey. |
Glossary of Terms
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)
Prophylactic IV Antibiotics: Drugs
administered into a vein to prevent the spread
or occurrence of infection. |
