III. Measure Name: Healthcare Worker (HCW) Hand Hygiene Measure Description: HCW hand hygiene is being monitored on each unit with a minimum of 10 observations” during a 24-hour period per month. This is currently the star” and the “direct “gold most reliable method for assessing adherence rates. Type of Measure: Performance Improvement Results Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD 1Q2017 Knox: 93% 87% 90% Target: HCW hand 93% hygiene sustained level Hamlin: 100% 83% 92% of compliance compliance 87% that approaches rate per unit Chamberlain: 90% per quarter 100% 83% 92% 93% Data Analysis: In 2Q2018, Knox’s compliance rate was 87%, a decrease of 6% from the previous quarter; Hamlin’s compliance rate was 83%, a decrease of 17% from the previous quarter; and Chamberlain’s compliance rate was 83%, a decrease of 17% from the previous quarter. Action Plan: Continue to monitor HCW hand hygiene compliance per CDC guidelines. Educate staff on how missed opportunities could be corrected. IV. Measure Name: Patient Hand Hygiene Patient hand hygiene is being monitored on each unit with a minimum of 4 Measure Description: observations” during a 24-hour period, per month. This is currently the star” and the “direct “gold most reliable method for assessing adherence rates. Type of Measure: Performance Improvement Results Unit Baseline 1Q2018 2Q2018 3Q2018 4Q2018 YTD 1Q2018 Target: Pt hand Knox: 83% 87% 85% sustained level 83% hygiene
III. Measure Name: Healthcare Worker (HCW) Hand Hygiene Measure Description: HCW hand hygiene is being monitored on each unit with a minimum of 10 “direct observations” during a 24-hour period per month. This is currently the “gold star” and the most reliable method for assessing adherence rates. Type of Measure: Performance Improvement Results Unit Baseline 1Q2017 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target: sustained level of compliance that approaches 90% HCW hand hygiene compliance rate per unit per quarter Knox: 93% 93% 87% 90% Hamlin: 87% 100% 83% 92% Chamberlain: 93% 100% 83% 92% Data Analysis: In 2Q2018, Knox’s compliance rate was 87%, a decrease of 6% from the previous quarter; Hamlin’s compliance rate was 83%, a decrease of 17% from the previous quarter; and Chamberlain’s compliance rate was 83%, a decrease of 17% from the previous quarter. Action Plan: Continue to monitor HCW hand hygiene compliance per CDC guidelines. Educate staff on how missed opportunities could be corrected. IV. Measure Name: Patient Hand Hygiene Measure Description: Patient hand hygiene is being monitored on each unit with a minimum of 4 “direct observations” during a 24-hour period, per month. This is currently the “gold star” and the most reliable method for assessing adherence rates. Type of Measure: Performance Improvement Results Unit Baseline 1Q2018 1Q2018 2Q2018 3Q2018 4Q2018 YTD Target: sustained level Pt hand hygiene Knox: 83% 83% 87% 85%
DDPCQuarterlyReport2Q2018.docx