screens 68.3% 68.3% 68.3% completed 41/60 Actual 41/60 41/60 accurately Data Analysis: results indicate there is opportunity for improving the accuracy of the information gathered on the nutrition screen. The nutrition screen is completed by the nurse responsible for the admission. Action Plan: Determine similarities within the incomplete nutrition screens. Provide proper training to the nurses responsible for completing the nutrition screen upon admission. Identify the diagnoses on the nutrition screen that have common inaccuracies. STRATEGIC PERFORMANCE EXCELLENCE III. Measure Name: Hand Hygiene Compliance Measure Description: Supervisory staff: including the Food Service Manager and Cook III’s, will observe all dietary employees, as they return from break, for proper hand hygiene. Type of Measure: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Percent of 90% 95% Dietary Target FY 2015 employees 97.7% washing 96.3% 96.3% 338/346 hands after 343/356 343/356 Actual break Data Analysis: The results of this quarter remain above 90%. This measure began as a performance improvement indicator in the first quarter of FY13 with 58% compliance. By the third quarter of FY15 the compliance rate had risen to above 90% and remains there. Action Plan: Continue to have line supervisors monitor handwashing compliance after breaks. Provide hand hygiene training annually Encourage front line supervisors to promote hand hygiene with their staff throughout the day.
screens completed accurately 68.3% 41/60 Actual 68.3% 41/60 68.3% 41/60 Data Analysis: results indicate there is opportunity for improving the accuracy of the information gathered on the nutrition screen. The nutrition screen is completed by the nurse responsible for the admission. Action Plan: Determine similarities within the incomplete nutrition screens. Provide proper training to the nurses responsible for completing the nutrition screen upon admission. Identify the diagnoses on the nutrition screen that have common inaccuracies. STRATEGIC PERFORMANCE EXCELLENCE III. Measure Name: Hand Hygiene Compliance Measure Description: Supervisory staff: including the Food Service Manager and Cook III’s, will observe all dietary employees, as they return from break, for proper hand hygiene. Type of Measure: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Percent of Dietary employees washing hands after break FY 2015 97.7% 338/346 90% 95% Actual 96.3% 343/356 96.3% 343/356 Data Analysis: The results of this quarter remain above 90%. This measure began as a performance improvement indicator in the first quarter of FY13 with 58% compliance. By the third quarter of FY15 the compliance rate had risen to above 90% and remains there. Action Plan: Continue to have line supervisors monitor handwashing compliance after breaks. Provide hand hygiene training annually Encourage front line supervisors to promote hand hygiene with their staff throughout the day.
2016Q1.docx