6G: Safe Practice # 19 Hand Hygiene 19.1, 19.4: How will institutions measure or monitor progress with this Safe Practice? The following elements may be monitored as part of a performance improvement project: Implementation of the nationally-approved hand hygiene guidelines as established by the Centers for Disease Control (CDC) Hospital-acquired infection rates as a pre- and post-test after the implementation of interventions, such as bedside dispensers or other equipment for hand decontamination made available to staff 19.4: Will use of the CDC guidelines for hand hygiene meet this Safe Practice? Yes. Please see: . 19.4b: Would a general hand hygiene be enough to count as a formal “campaign” performance improvement program? ? No. To meet this element, hospitals should be employing one or more of the following: technology systems to monitor hand hygiene compliance, use of secret observers, and measuring use of hand hygiene product. 6H: Safe Practice # 23 Prevention of Healthcare-Associated Complications in Ventilated Patients 23.1a and 23.2a: Which roles are included in senior administrative and clinical leadership? COO, CEO, CNO, CMO, Head of Pharmacy, and respiratory therapists. 23.3a: Which staff roles should receive education/knowledge transfer and skill development programs on ventilator use and its complications? Physicians, nurses, pharmacists, and respiratory therapists. 23.4c: Do ALL ventilated patients and/or their families need to be educated on prevention measures involved in the care of the ventilated patient? What if the patient is unconscious and has no family members? In that situation, it would be appropriate to document that the patient is unresponsive, has no family members, and therefore no opportunity for education. When the patient does not have family members, it would be appropriate to adopt a broader definition of to include loved ones and “family” those who will be caring for the patient. 23.4: How can pediatric hospitals address the expectations of the Action answer of this Safe Practice? The action expectations of this survey question may be satisfied by implementation and adoption of the Pediatric elements for patients 18 years and younger as outlined in this NQF Safe Practice Additional Specifications. Page Intentionally Left Blank
6G: Safe Practice # 19 Hand Hygiene 19.1, 19.4: How will institutions measure or monitor progress with this Safe Practice? The following elements may be monitored as part of a performance improvement project: Implementation of the nationally-approved hand hygiene guidelines as established by the Centers for Disease Control (CDC) Hospital-acquired infection rates as a pre- and post-test after the implementation of interventions, such as bedside dispensers or other equipment for hand decontamination made available to staff 19.4: Will use of the CDC guidelines for hand hygiene meet this Safe Practice? Yes. Please see: . 19.4b: Would a general hand hygiene “campaign” be enough to count as a formal performance improvement program? ? No. To meet this element, hospitals should be employing one or more of the following: technology systems to monitor hand hygiene compliance, use of secret observers, and measuring use of hand hygiene product. 6H: Safe Practice # 23 Prevention of Healthcare-Associated Complications in Ventilated Patients 23.1a and 23.2a: Which roles are included in senior administrative and clinical leadership? COO, CEO, CNO, CMO, Head of Pharmacy, and respiratory therapists. 23.3a: Which staff roles should receive education/knowledge transfer and skill development programs on ventilator use and its complications? Physicians, nurses, pharmacists, and respiratory therapists. 23.4c: Do ALL ventilated patients and/or their families need to be educated on prevention measures involved in the care of the ventilated patient? What if the patient is unconscious and has no family members? In that situation, it would be appropriate to document that the patient is unresponsive, has no family members, and therefore no opportunity for education. When the patient does not have family members, it would be appropriate to adopt a broader definition of “family” to include loved ones and those who will be caring for the patient. 23.4: How can pediatric hospitals address the expectations of the Action answer of this Safe Practice? The action expectations of this survey question may be satisfied by implementation and adoption of the Pediatric elements for patients 18 years and younger as outlined in this NQF Safe Practice Additional Specifications. Page Intentionally Left Blank
2016Survey_Final_1.docx