Bleeding Swelling Pain Muscle soreness Nov Feb May N/A Mouth care 100% 100% N/A 0/0 3/3 6/6 0/0 Diet Sept Dec Mar June Signs/symptoms of infection N/A 100% 100% 100% The patient, post procedure tooth extraction, 0/0 2/2 4/4 1/1 will verbalize understanding of the above by Total Total Total repeating instructions given by Dental 100% 100% 100% 100% Assistant/Hygienist. 3/3 14/14 14/14 4/4 Post dental extraction patients will receive a follow-up phone call from the clinic within 24 hours of procedure to assess for post procedure complications JOINT COMMISSION Healthcare Acquired Infections Monitoring and Management NPSG.07.03.01 Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals. Infection Control Responsible Party: George Davis, MD, Chairperson of Infection Control Committee Kathleen Mitton, RN, Infection Control Nurse I. Measure Name: Hospital Associated Infection (HAI) Rate Measure Description: Monitor and measure of Hospital Associated Infections. Measure Type: Quality Assurance Results Target Unit Baseline 2Q2015 3Q2015 4Q2015 1Q2016 YTD Within 1 12 4 HAI/IC 7 HAI/IC 4 HAI/IC HAI – STDV of Hospital FY 2014 HAI/IC Rate 2.2 Rate 1.1 Rate 0.83 1.46 the Mean Associated 1 STDV Rate 1.7 Infection within the 1 STDV 1 STDV At 1 Rate mean within the within the Actual STDV mean mean Outcome A Hospital Acquired Infection (HAI) is any infection present, incubating or exposed to more than 72 hours after admission (unless the patient is off hospital grounds during that time) or declared by a physician, a physician’s assistant or advanced practice nurse to be a HAI.
Bleeding Swelling Pain Muscle soreness Mouth care Diet Signs/symptoms of infection The patient, post procedure tooth extraction, will verbalize understanding of the above by repeating instructions given by Dental Assistant/Hygienist. Post dental extraction patients will receive a follow-up phone call from the clinic within 24 hours of procedure to assess for post procedure complications Nov 100% 3/3 Dec 100% 2/2 Total 100% 14/14 Feb 100% 6/6 Mar 100% 4/4 Total 100% 14/14 May N/A 0/0 June 100% 1/1 Total 100% 4/4 N/A 0/0 Sept N/A 0/0 100% 3/3 JOINT COMMISSION Healthcare Acquired Infections Monitoring and Management NPSG.07.03.01 Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals. Infection Control Responsible Party: George Davis, MD, Chairperson of Infection Control Committee Kathleen Mitton, RN, Infection Control Nurse I. Measure Name: Hospital Associated Infection (HAI) Rate Measure Description: Monitor and measure of Hospital Associated Infections. Measure Type: Quality Assurance Results Target Unit Baseline 2Q2015 3Q2015 4Q2015 1Q2016 YTD Within 1 STDV of the Mean Hospital Associated Infection Rate FY 2014 1 STDV within the mean 4 HAI/IC Rate 2.2 7 HAI/IC Rate 1.1 4 HAI/IC Rate 0.83 12 HAI/IC Rate 1.7 HAI – 1.46 Actual Outcome At 1 STDV 1 STDV within the mean 1 STDV within the mean A Hospital Acquired Infection (HAI) is any infection present, incubating or exposed to more than 72 hours after admission (unless the patient is off hospital grounds during that time) or declared by a physician, a physician’s assistant or advanced practice nurse to be a HAI.