CHS

1
CHS Performance Improvement Priorities for 2009

• PI Council, MEC CHS Executive Staff

2
INFECTION PREVENTION

• Reduce healthcare acquired infections (HCAIs) by
  50 by December 31, 2009 through consistent
  organization-wide application of evidence-based
• 95 compliance with CDC hand hygiene guidelines
• 95 compliance PPE use and disposal guidelines
• 75 of eligible CHS employees vaccinated for flu

3
PATIENT IDENTIFICATION

• Eliminate incorrect patient identification by
  December 31, 2009 through the following
  strategies
• Consistent verification of patients using
  two-organizationally approved identifiers
• Consistent patient/family involvement in patient
  identification processes
•  

4
Proposed Dissemination Strategies

• Leadership meeting, Medical Staff mtgs
• CHS Intranet, with data on how we are doing
• Departmental specific data J-Co webpage
• Tracers
• Various internal Newsletters   
• Executive Rounds to ensure employees can
  articulate priorities and demonstrate knowledge
  of goals and how they affect their role at CHS

5
Nosocomial Infection Markers
6
Patient ID
7
Summary

• Situation Significant improvement is needed in
  these two areas for patient safety
• Background Both are NPSGs and recently
  recognized by outside surveyors that consistent
  practice was not evident
• Assessment Involvement by all levels of staff
  is needed to sustain improvement
• Recommendation Discuss these PI priorities with
  your staff and their role in the efforts