CHS’ Performance Improvement Priorities for 2009 PI Council, MEC & CHS Executive Staff

INFECTION PREVENTION 95% compliance with CDC hand hygiene guidelines 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

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  

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

Nosocomial Infection Markers

Patient ID

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