Hand Hygiene Campaign has been approved by the ASC Governing 1. Achieve 95% Board Consistently meet observational hand hygiene Compliance by all HCWs and compliance with A physician champion has been audit compliance of 95% or better sustainability of improvements named hand hygiene Hand sanitizers installed on anesthesia carts Prevent surgical site infections by: Using the CDC SSI bundle continue to be monitored and Audit surgical services for continuous Difficulty obtaining prophylactic processes audited compliance with antibiotic prophylactic 2. Reduce ATB orders in time Education was provided to the ASC guidelines for surgical procedures surgical site Not able to provide CHG staff to improve compliance with SSI Audit compliance with eligible surgical infections by baths to all patients bundle patients receiving appropriate prophylactic 10% due to time constraints antibiotics within one hour prior to surgical CHG preoperative bedside baths incision time were implemented pre-operatively All patients will have a preoperative bath with a CHG product Offer free vaccine to all employees 3. Increase ASC during immunization clinic Influenza Increase employee, medical staff, volunteer, Difficult to schedule clinic when Provide employees with a list of Vaccination and all HCP influenza vaccination rates everyone is available times and locations where they can Rates to 90% receive influenza immunizations DISCLAIMER: All data and information provided by the Oregon Patient Safety Commission is for informational purposes only. The Oregon Patient Safety Commission makes no representations that the patient safety recommendations will protect you from litigation or regulatory action if the recommendations are followed. The Oregon Patient Safety Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these recommendations.
1. Achieve 95% compliance with hand hygiene Consistently meet observational hand hygiene audit compliance of 95% or better Hand Hygiene Campaign has been approved by the ASC Governing Board A physician champion has been named Hand sanitizers installed on anesthesia carts Compliance by all HCWs and sustainability of improvements 2. Reduce surgical site infections by 10% Prevent surgical site infections by: Using the CDC SSI bundle Audit surgical services for continuous compliance with antibiotic prophylactic guidelines for surgical procedures Audit compliance with eligible surgical patients receiving appropriate prophylactic antibiotics within one hour prior to surgical incision time All patients will have a preoperative bath with a CHG product continue to be monitored and processes audited Education was provided to the ASC staff to improve compliance with SSI bundle CHG preoperative bedside baths were implemented pre-operatively Difficulty obtaining prophylactic ATB orders in time Not able to provide CHG baths to all patients due to time constraints 3. Increase ASC Influenza Vaccination Rates to 90% Increase employee, medical staff, volunteer, and all HCP influenza vaccination rates Offer free vaccine to all employees during immunization clinic Provide employees with a list of times and locations where they can receive influenza immunizations Difficult to schedule clinic when everyone is available DISCLAIMER: All data and information provided by the Oregon Patient Safety Commission is for informational purposes only. The Oregon Patient Safety Commission makes no representations that the patient safety recommendations will protect you from litigation or regulatory action if the recommendations are followed. The Oregon Patient Safety Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these recommendations.
1.06_IPP_Annual_Goals_Evaluation_Tool_1.docx