Check all boxes that apply.
In regard nosocomial infections related to inadequate hand washing,
our organization is:
| 22.1 Aware of our performance improvement
opportunity in this area in that . . . |
| X |
We have undertaken an enterprise-wide educational effort
addressing the frequency and severity of nosocomial infections
within our patient population and potential impact of performance
improvement practices related to the absence of or inadequate
hand washing, within the 12 months prior to submitting this
survey, as documented by meeting minutes, attendance or completion
records. |
| Within the last 12 months
prior to submitting this survey, the organization has: |
|
performed an enterprise-wide evaluation of the frequency
and severity of nosocomial infections. |
| |
submitted a summary report to administration and governance
with recommendations for measurable improvement targets and
further action. |
| For the last 12 months or more, |
| X |
the organization, through ongoing evaluation, has monitored
and continues to report results of measurable improvement targets
related to this area to administration and governance. |
| 22.2 Accountable to this issue as evidenced
. |
| X |
by departmental/clinical service line managers all being directly
accountable for the patient safety area through documented personal
performance reviews or personal compensation incentives, or
other organization-specific documented evaluation review processes. |
| |
by having developed documented personal performance reviews
or personal compensation plans, or other organization-specific
documented evaluation review processes which now hold senior
executives in addition to department/clinical service line managers
accountable for this safe practice. |
| |
the organization has either a Patient Safety Officer or an
Administrator who oversees organizational patient safety regularly
reporting to the CEO and the Board performance improvement metrics
related to this safe practice and is directly accountable for
this through documented personal performance reviews or compensation,
or other organization-specific documented evaluation review
processes. |
| 22.3 Invested in our ability to deal with
this issue by . . . |
| X |
Within the last 12 months prior to submitting this survey,
conducting staff education/knowledge transfer and skill development
programs as documented by meeting minutes attendance or completion
records. |
| Our organization has: |
| X |
documented expenditures on staff education related to
this safe practice in the previous year. |
| |
has incorporated additional funding in the new budget. |
| 22.4 Taking additional actions to ensure
that . . . |
| |
explicit organizational policies and procedures are in place
across the entire enterprise to prevent nosocomial infections
due to inadequate hand washing techniques including CDC guidelines
with category IA, IB, or IC evidence with routine measurement
of compliance and process improvement addressing compliance
within the 12 months prior to submitting this survey. |
| |
by having implemented a formal performance improvement program
addressing nosocomial infections (with regular performance measurement
and tracking improvement within the last 12 months) focused
on hand washing techniques and compliance. |
| X |
by having implemented an enterprise-wide performance improvement
program for hand washing compliance (with regular monitoring
and measurement of indicators within the last 12 months). |
| |
by having completed, in the last 12 months or more, a formal,
enterprise-wide performance improvement program addressing all
elements of this Safe Practice and Additional Specifications
with ongoing monitoring and measurement and subsequent process
improvement based on established targets. |
