HAI: 7 CAI: 1 Idiosyncratic Infections: 0 Patient Days: 7854 Plan: Ongoing surveillance JOINT COMMISSION II. Measure Name: Employee Hand Hygiene Rate Measure Description: Staff will observe the hand hygiene practice of nurses as they pass medications. (10 observations per month) will do ten (10) hand hygiene observations per month (before & after patient contact) in the milieu on the 7-3 shift. Staff will do ten (10) hand hygiene observations per month (before & after patient contact) in the milieu on the 3-11 shift Measure Type: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Employee >90% >90% >90% >90% >90% Target Hand 80% 98%* Hygiene FY 2015 95% (December 97 Compliance Actual 2015 only) Data: Saco Meds no data Upper Kennebec Meds – –100% Upper Saco Milieu 7-3 no data Upper Kennebec Milieu 7-3 100% – – Upper Saco Milieu 3-11 no data Upper Kennebec Milieu 3-11 100% – – Lower Kennebec Meds 100% Lower Saco Meds 100% – – Lower Kennebec Milieu 7-3 98% Lower Saco Milieu 7-3 100% – – Lower Kennebec Milieu 3-11 85% Lower Saco Milieu 3-11 100% – – Infection Control Nurse position vacant – *Note: The Infection Control Nurse position was vacated in November 2015. Hand Hygiene data was only available for December 2015 for 3 of the 4 patient units. Data will be provided in the next quarterly report.
HAI: 7 CAI: 1 Idiosyncratic Infections: 0 Patient Days: 7854 Plan: Ongoing surveillance JOINT COMMISSION II. Measure Name: Employee Hand Hygiene Rate Measure Description: Staff will observe the hand hygiene practice of nurses as they pass medications. (10 observations per month) will do ten (10) hand hygiene observations per month (before & after patient contact) in the milieu on the 7-3 shift. Staff will do ten (10) hand hygiene observations per month (before & after patient contact) in the milieu on the 3-11 shift Measure Type: Performance Improvement Results Unit Baseline 1Q2016 2Q2016 3Q2016 4Q2016 YTD Target Employee Hand Hygiene Compliance 80% FY 2015 >90% >90% >90% >90% >90% Actual 95% 98%* (December 2015 only) 97 Data: Saco Meds – no data Upper Kennebec Meds –100% Upper Saco Milieu 7-3 – no data Upper Kennebec Milieu 7-3 – 100% Upper Saco Milieu 3-11 – no data Upper Kennebec Milieu 3-11 – 100% Lower Kennebec Meds – 100% Lower Saco Meds – 100% Lower Kennebec Milieu 7-3 – 98% Lower Saco Milieu 7-3 – 100% Lower Kennebec Milieu 3-11 – 85% Lower Saco Milieu 3-11 – 100% Infection Control Nurse – position vacant *Note: The Infection Control Nurse position was vacated in November 2015. Hand Hygiene data was only available for December 2015 for 3 of the 4 patient units. Data will be provided in the next quarterly report.
2016Q2.docx