QAPI Program Utilization_Manual

PERFORMANCE IMPROVEMENT OUTCOME MONITORING Patient Safety Goal: Reduce the Risk of Healthcare-Associated Infections Date: Performance Measures/Outcomes Method Volume Measure/ Numerator Benchmark Goal Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total - # of times random observation identified staff member not following hand hygiene protocol Random physical observation of clinical staff members Total = total observations per month Observations conducted by supervisor or designee # of times protocol breached/ # of observations 0/# of observations 0% - # of hand rub solution dispensers noted to be empty during random inspection Random physical inspection of hand washing tech Total = total inspections per month Observations conducted by supervisor or designee # of follow techniques # of inspections 0/# of inspections - Volume of hand rub solution usage measurements are above baseline Monthly solution volume measurement Total solution volume per patients/visit # of times volume above baseline 0/1000 patient/visit - # of clinical staff members identified with natural nails over one-quarter (1/4) inch in length Random observation of clinical staff per month Observations conducted by supervisor or designee # of staff members with nails over one-quarter (1/4) inch in length 0/# of observations 140