Quality Improvement Indicators
(posted March 3, 2010)
We have many ways of judging our success as a hospital. The satisfaction of employees and patients, the number of patients we see, the number of surgeries we perform, our Magnet status and the support of our generous donors. These are all excellent ways to measure our many successes, but we also need other, more detailed ways to gauge our improvements. That is why 4 clinical quality improvement indicators have been chosen for 2010. Some are standing goals that we seek to continually improve each year and others are new. All are specific to The Miriam. Here, I seek to briefly explain each indicator and why it was chosen.
The indictors that were carried over from 2009 are hospital acquired pressure ulcers in critical care patients, falls with injury and antibiotic compliance for patients with severe sepsis and septic shock. The first two are Magnet and National Database of Nursing Quality indicators and are classified as “never events” by the Center for Medicare and Medicaid. The third indicator is important to The Miriam Hospital because evidence shows that timely antibiotics administration improves patient outcomes. Although we had favorable results in 2009, we continue to make these indicators a priority.
The Miriam’s new indicators are pain management and time spent in the emergency department. Pain management is a priority of the Joint Commission and a strong indicator of patient satisfaction. The goal for the emergency department is to transfer ED patients to the ICU in under 90 minutes, which will decrease ED overcrowding, improve patient satisfaction and help improve another quality indicator, antibiotics administration to sepsis patients.
The final indicator is hand hygiene, a multiyear goal for The Miriam. Hospitalized patients are more susceptible to hospital acquired infection and many infections are caused by pathogens transmitted via the unwashed hands of health care workers. Hand hygiene is the single most important procedure for preventing hospital infections. In 2009, we sought a 70 percent compliance with hand hygiene; we achieved 77 percent compliance. This means that 77 percent of the time, our anonymous observers noted that all personnel washed their hands going into and exiting from the observed room. In 2010, we hope to continue that good work and reach a total of 80 percent on our way to 100 percent compliance.
If you have any questions about these indicators, feel free to contact your manager.
Hard work will be needed to accomplish all of these goals. The Miriam, however, is no stranger to hard work. We will meet these goals as we have met many others, and continue to improve the patient experience.