Human Resources Person Responsible: Rice, Human Resources Manager I. Measure Name: License Reviews Measure Description: Ensuring that licenses/registry entries are verified via the appropriate source to hire for all licensed (or potentially licensed) new hires. Type of Measure: Quality Assurance Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD 100% 100% 100% 100% 100% Percentage Target FY2014 Licenses 98% 100% 100% 100% 100% 100% Reviewed 24/24 15/15 22/22 20/20 81/81 Actual Data Analysis: During 4Q2017, were 25 new hires. Of those, 20 were licensed, or potentially licensed. License verification was completed on all 20 employees with potential licenses. Action Plan: No action is needed at this time. Infection Control Person Responsible: Donna Bradeen, RN, Infection Control Nurse I. Measure Name: Employee Hand Hygiene Rate Measure Description: will observe the hand hygiene practice of nurses as they pass medications. (10 observations per month) Staff will do 10 hand hygiene observations per month (before & after patient contact) in the milieu on the 7AM-7PM shift. Staff will do 10 hand hygiene observations per month (before & after patient contact) in the milieu on the 7PM-7AM shift Measure Type: Performance Improvement
Human Resources Person Responsible: Rice, Human Resources Manager I. Measure Name: License Reviews Measure Description: Ensuring that licenses/registry entries are verified via the appropriate source to hire for all licensed (or potentially licensed) new hires. Type of Measure: Quality Assurance Results Unit Baseline 1Q2017 2Q2017 3Q2017 4Q2017 YTD Target Percentage Licenses Reviewed FY2014 98% 100% 100% 100% 100% 100% Actual 100% 24/24 100% 15/15 100% 22/22 100% 20/20 100% 81/81 Data Analysis: During 4Q2017, were 25 new hires. Of those, 20 were licensed, or potentially licensed. License verification was completed on all 20 employees with potential licenses. Action Plan: No action is needed at this time. Infection Control Person Responsible: Donna Bradeen, RN, Infection Control Nurse I. Measure Name: Employee Hand Hygiene Rate Measure Description: will observe the hand hygiene practice of nurses as they pass medications. (10 observations per month) Staff will do 10 hand hygiene observations per month (before & after patient contact) in the milieu on the 7AM-7PM shift. Staff will do 10 hand hygiene observations per month (before & after patient contact) in the milieu on the 7PM-7AM shift Measure Type: Performance Improvement
2017Q4.docx