All patients with tooth extractions will be assessed and have teaching post procedure on the following topics, as provided by the Dentist or Dental Assistant: Oct Jan April July Bleeding 100% 100% 100% 100% Swelling 9/9 4/4 3/3 3/3 Pain Nov Feb May Aug Muscle soreness 100% 100% N/A N/A Mouth care 3/3 6/6 0/0 0/0 100% Diet Dec Mar June Sept 35/35 Signs/symptoms of infection 100% 100% 100% N/A The patient, post procedure tooth extraction, 2/2 4/4 1/1 0/0 will verbalize understanding of the above by Total Total Total repeating instructions given by Dental 100% 100% 100% 100% Assistant/Hygienist. 14/14 14/14 4/4 3/3 Post dental extraction patients will receive a follow-up 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 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 HAI/IC Hospital FY 2014 Rate 2.2 Rate 1.1 Rate 0.83 1.46 the Mean Rate 1.7 Associated 1 STDV Infection within the 1 STDV 1 STDV At 1 Rate mean within the within the Actual STDV mean mean Outcome
All patients with tooth extractions will be assessed and have teaching post procedure on the following topics, as provided by the Dentist or Dental Assistant: 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 call from the clinic within 24 hours of procedure to assess for post procedure complications Oct 100% 9/9 Nov 100% 3/3 Dec 100% 2/2 Total 100% 14/14 Jan 100% 4/4 Feb 100% 6/6 Mar 100% 4/4 Total 100% 14/14 April 100% 3/3 May N/A 0/0 June 100% 1/1 100% 4/4 July 100% 3/3 Aug N/A 0/0 Sept N/A 0/0 Total 100% 3/3 100% 35/35 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 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
Section-13-Riverview-Report-FY16Q1.docx