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 staff with artificial nails in high-risk patients (Infection disease patients, bloodborne, other) Random observation of clinical staff per month Observations conducted by supervisor or designee # of staff members with artificial nails 0/# of observations - # of healthcare associated- infections Infection Control Surveillance reporting monthly per unit # of discharges + # of clean cases 0/total volume - # of sentinel events related to healthcare associated- infection Cases reported (incident reporting) Infection Control reporting # of sentinel events/ discharges 141