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Prevent Adverse Outcomes Through Development of Infection Prevention and Quality Improvement Program

Helpful reminders that can help to ensure safe patient outcomes and reduce risk of infection in your healthcare facility

october 2021

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

Happy International Infection Prevention Week Oct 17-23, National Healthcare Quality Week Oct 17-23, National Health Education Week Oct 18-22, Respiratory Care Week Oct 24-30, Medical Ultrasound Awareness Month, National Breast Cancer Awareness Month and National Physical Therapy Month from HCE!


Infection Prevention Tips


Although we cannot say enough about the importance of good hand hygiene compliance, we can assure you that in general, compliance rates have gone up significantly throughout the course of the Covid-19 pandemic. This is truly something to celebrate! It is still critical to ensure that employees are well trained on proper hand hygiene technique, however. For instance, do staff understand when to wash their hands with soap and water vs. hand sanitizer? It seems simple, but we can assure you that when asking this question, you will get an even mix of responses.


Hand sanitizer is perfectly acceptable when performing most general duties. It is quick, requires very little activity and studies suggest that this method is 99.99% effective in preventing the spread of germs and infection. Be sure employees do understand that this is not an acceptable method of cleaning their hands when dealing with any blood or bodily fluids. The soap and water method are considered to be most effective when caring for patients who are on enteric isolation precautions. If your organization has a well trained Infection Preventionist on staff, then rest assured that there is a good chance that your employees are aware of which method to choose when providing day to day care to patients.


It is important to incorporate this training into your existing infection prevention program. This education should be done as a part of any new employee orientation as well as on an annual basis. Never assume that even your most seasoned healthcare team members understand which method to choose when incorporating best practice into their daily routine.


Healthcare Quality Improvement Tips 


Proper identification of a patient would seem to most a simplistic of tasks for most employees to be able to complete. This continues to be a point of focus with regulatory agencies because of the inconsistencies in methods used to obtain proper identification of patients. Incorrect identification of a patient can lead to a multitude of errors including, but not limited to medication errors, incorrect diagnosis, patients undergoing unnecessary treatments and or procedures. There is also the risk of patient health information being wrongfully released from the healthcare facility. These types of errors stemming from incorrect patient identification can lead to significant legal and financial implications for any healthcare entity.


These errors does not stop just with the patient. Many times you will hear incorrect patient identification information exchanged between departments.


Remember, there are  only two data points  recognized as acceptable methods of identifying patients. These include verification of a  patient's name  and  date of birth . Once again, not only is this education critical for all new employees, but we cannot emphasize enough the importance of annual and ongoing training. 


In Summary


It is hard to believe that we still continue to miss the mark on what would seem to be some of the most simplistic tasks, but the fact is that we continue to do so. Adverse outcomes can be prevented and eliminated through development of comprehensive Infection Prevention and Quality Improvement Programs in addition to new and ongoing employee education. 

March 7, 2025
Providing respiratory care services can be a challenge for hospitals, especially during months when respiratory illnesses are at their peak throughout communities.
February 10, 2025
It is that time of year again. At least for acute care hospitals, long-term acute care (LTAC) hospitals and inpatient rehabilitation facilities (IRF) who report to The National Healthcare Safety Network (NHSN). If annual surveys are not reported by March 1 st , then your organization will not be permitted to enter monthly reporting plans until the annual survey has been completed. Although there are just a few weeks to go, early planning is the key. It is important to consider that responses to the Annual Survey questions are a collaborative effort. Planning a meeting in advance with key stakeholders will help to ease the stress of completing what some may consider to be a daunting task. Be sure to coordinate with Facilities Managers, Pharmacists, Laboratory, Nursing, Infection Prevention and Quality leaders on annual survey responses. Although individuals who are responsible for report submission may find that some of the data has not changed significantly from the previous year, we have identified that some questions have been removed while additional questions have been added. If you are new to NHSN reporting and have not yet completed an annual survey, you will find an alert reminding you on your dashboard upon logging in. Keep in mind that the survey you are completing requires data from the previous calendar year. You will be submitting data for 2024 due March 1 st , 2025. There are a variety of questions that will require information about metrics, facility type, infection prevention practices, laboratory testing methods, water quality management, and antimicrobial stewardship practices for example. Instructions on completing your organization’s annual survey click on the link below that corresponds with your facility type: Instructions for Completing Annual Hospital Survey Instructions for Completing LTAC Annual Survey Instructions for Completing IRF Annual Survey OSHA requires the following facilities to complete an annual occupational injury and Illness Report: Ambulatory Health Care Servies General Medical and Surgical Hospitals Psychiatric and Substance Abuse Hospitals Specialty Hospitals Skilled Nursing Facilities For a complete list of facilities required to report annually via electronic submission and for additional information on Standard 1904 Subpart E Appendix B click on the following link: OSHA Injury and Illness Reporting Requirements . Much like NHSN annual surveys, this reporting is also for the prior calendar year. Your deadline for submission is March 2, 2025. If your organization has not previously been reporting, please note that you will need to set up an Injury Tracking Application (ITA) account. For complete instructions, click on the following link User Guide . Individuals who are responsible for report completion and submission should have a clear understanding of criteria that constitutes a work-related injury. They will also need to know if the employee missed days of work because of injury or illness. If an employee was restricted from usual work activities or reassigned to a new role as a result of the injury or illness this information must be documented. If an employee required care beyond basic first aid, this will also need to be reported. Reporters should not include Protected Health Information (PHI). For a brief tutorial on OSHA annual reporting requirements, click on the following link OSHA Injury and Illness Reporting . Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges. Whether you are in need of mock surveys, leadership training, corrective action plans or ongoing support services, we can help! We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry. Be sure to browse Our Website for a full list of services we provide. Contact us today at +1 (800) 813-7117 to schedule a free consultation. References: https://www.cdc.gov/nhsn/forms/instr/57_103-toi.pd https://www.osha.gov/laws-regs/regulations/standardnumber/1904/1904SubpartEAppB https://www.osha.gov/sites/default/files/ita_user_guide.pdf https://www.osha.gov/sites/default/files/osha_rktutorial.pdf
A hospital room with a bed and a lot of medical equipment.
January 13, 2025
In 2002 The Joint Commission (TJC) first established the National Patient Safety Goals (NPSG) Program. In 2003, TJC rolled out the first set of NPSG’s. Each year, TJC prioritizes patient safety goals for various healthcare programs.
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