Committee Meeting on Quality Improvement

Quality Improvement Committee Meeting

The Environment of care is also known as any site where treatment of patients is administered, including outpatient and inpatient settings. The primary purpose of the Environment of care is to ensure an effective, functional, and safe environment for the patients and staff members. Following the meeting report, occupational safety and health administration statistics reported the status of environment care based on specific parameters, including; safety, security, emergency management, fire safety, Hazardous materials, utility management, and medical equipment. According to the report, injuries and illnesses seem upward (Parvizi et al., 2017). For instance, in 2019 and 2020, 85 and 90 cases of injuries and illnesses were recorded, respectively. However, there is improved security compliance among the members through wearing the official badge. Also, a positive trend in emergency management has been recorded until the first quarter of 2021. Unfortunately, the response to fire safety still fluctuates, with some cases recording an inadequate response while others are recording a positive reaction to the fire plan race. Otherwise, there is positive progress towards compliance to hazardous materials and adherence to the utility’s management. Finally, some special machines like power strips and power taps have been installed on medical equipment to continue in 2021. In addition, the compliance will be evaluated during the departmental rounding by the Biomed (Parvizi et al., 2017).

Consequently, to improve safety, the appropriate measure was initiated and included: one hourly team review and rounding, 4 Ps review at the onboarding program, an attempt by the Nursing leadership to evaluate the hourly rounds team performance consistency; however, this was hindered due to lack of appropriate software. Also carried out by the nursing leadership was rounding audit and hourly observance together with in-time coaching. Notably, all the patients were put on the yellow socks, even though the socks sizes were not personalized; it is a work in progress (Parvizi et al., 2017).

On food and Nutrition, varying indicators like clinical indicators and operations indicators have been used to indicate malnutrition. According to clinical indicators, there is a significant improvement in diet intake affected by improved communication between the physician, ClinDoc team, and the dietitians. On the other hand, the operations indicator shows that food quality is beyond the patients’ expectations. However, there is an understaffing concern. Subsequently, there are various initiatives aimed at enhancing significant improvements. Such initiatives include filling vacant positions to eliminate the understaffing challenge, reviewing specific unit scores, and frequent tests on the tray temperatures (Sampson, 2018).

About infection prevention, the data and goals for the year 2021 were presented. However, due to covid-19 in 2020, the determination of goals was based on 2019 infection rates. According to the findings, the 2020 GLABSI was 8, and an improvement group for 2021 GLABSI had been created. Additionally, there were suggestions to include the residents in the project. Also discussed was the GLABSI action plan (Cosper et al., 2017).

On the other hand, according to the data provided, the 2020 CAUTI was 4, and details were presented. Subsequently, the CAUTI action plan for the year 2021 was availed, and improvement groups were formed. Various interventions were developed, focusing on individual units and rounding. Moreover, the 2021 surgical site infection plan was reviewed to concentrate on postop dosing, antibiotics, and dosing for more lengthy procedures. MRSA (methicillin-resistant Staphylococcus aureus), a type of bacteria resistant to multiple antibiotics, was 14 in 2020. Apart from the various challenges discussed, some initiatives were put in place. For instance, the Nasal screen was placed in the CCU as of 1st of April, decolonization of the CCU Universally was being considered. The documentation of CHG bathing was considered an opportunity for improvement. Consequently, the presentation and review of hand hygiene were done with 91% as the current compliance, thus, raising the need to heighten observation on hand hygiene (Sampson, 2018).

The perioperative services were discussed, including various indicators where the current performance was rated at 90% with patients moved on zoom stretcher’s goal tagged at 100%. Due to the implementation of surveillance and monitoring processes, March experienced a Spike. Nonetheless, more concentration was put upon orders through the reason for delay documentation, the starting time for every case, and care phases. Lastly, PAT’s surgical charts were availed for OR within three days (seventy-two hours), whereas the baseline data was determined in 2021 goal to be 50%. Consequently, progress on the stroke program was discussed, and acquisition of CTP/CTA was made to increase transfer times for the stroke patients in need of immediate thrombectomy. Effectively, door to CTA within the 1st quarter of 2021 indicated an improved transfer time. Also, a good TPA time was reported. However, there is a need for more improvement as care ladder nurses support the audit process due to the small dominator (Storr et al., 2017).

Furthermore, the 2021 imaging data was also presented and discussed. From the presentation, it was established that there is a good turnaround time and appropriate Fluoro cases. Equally, it was confirmed that Dosewatch alerts were within the target. Nevertheless, fluctuations were reported on sepsis bundle compliance, but there has been a simultaneous improvement over the previous years. Meanwhile, there is a need for more work on sepsis.