QAPI Program Utilization_Manual

QUALITY IMPROVEMENT ASPECTS OF CARE, INDICATOR, THRESHOLD Aspect Infections of MRSA, VRE, C-Diff, New Infections after admission Indicator Infections of MRSA, VRE, C-Diff, New Infections after admission that involves risk Threshold Less than 90 Sample 90-100% of patients records Data Source Infections reports, Infection Program Control Logs Methodology Infections Log review on a quarterly basis or more frequently basis if necessary Responsibility Results will be submitted to the Director of Nursing, Clinical Manager or designee whose responsibility will be to channel any identified problems to the appropriate staff for resolution and follow-up. The Director of Nursing, Clinical Manager or designee will be responsible to share any critical items/comments with the appropriate personnel for consideration, including BD and Infection Control Committee. Re-evaluation: next quarter, trends analyzes Plan if finding fail to meet acceptable standards: In-service to staff on Infection Control. Patient/ Family/Caregivers education on Infection Control. 126