Hartford Hospital has initiated multiple quality-improvement efforts with the goal of improving patient safety and medical outcomes as we provide compassionate, appropriate and efficient care.
Some of these efforts are highlighted below. For more information on other efforts, view our Patient Safety Action Group (PSAG) Newsletters. To view how we're doing with these quality-improvement efforts, click here.
Pneumonia Mortality - Hartford Hospital “Better Than the National Rate”
May 12, 2011
(CMS) Centers for Medicare and Medicaid addresses a number of quality measures in hospitals and report the hospital outcomes on Hospital Compare, www.hospitalcompare.hhs.gov. This website is a consumer-orientated website that offers information on how well hospitals provide recommended care to their patients.
Each year CMS posts diagnosis-specific mortality rates for each acute hospital through the Hospital Compare website and publicly reports how the hospital ranks against all others in the nation. As of 2014, hospital performance will be linked to Medicare reimbursement (Value Based Purchasing).
For Pneumonia Mortality, each hospital can have a ranking of:
- Below the National Rate
- No Different Than the National Rate
- Better Than the National Rate
Hartford Hospital was noted to have a rate that is "Better Than the National Rate". The Pneumonia Mortality calculation:
- Is mortality for all pneumonia discharges within 30 days of index admission
- Is Risk–Adjusted
- Is within the timeframe of July 2007–June 2010
CMS will be publicly posting for the time period of 2007-2010:
View our latest Pneumonia Vaccine Performance Measures
- The National rate was 11.9%
- Hartford Hospital rate was 9.9%
Process Improvement to Prevent Surgical Site Infections
April 14, 2011
Surgical site infections (SSI) are one of the most common types of health care acquired adverse events. These infections increase mortality, length of stay, readmission rate and personal costs for
the patients who develop them.
Hartford Hospital has incorporated many evidence based practices into the care of our surgical patients to help decrease the risk of developing an SSI.
A multidisciplinary team has been working closely with Cardiovascular Services over the last year to decrease variation in the processes that have been shown to help with the prevention of SSI in Cardiovascular patients.
A Cardiovascular Quality Assurance Checklist (CVQA) was developed by the team and implemented in September of 2010. The checklist is used by teams involved in the perioperative experience including the preoperative, intraoperative and postoperative areas. Each area completes a specific part of the checklist to ensure that we are performing all the elements identified by the team.
The first 6 months of information on these process improvement elements have shown that compliance with completing the CVQA is usually 85% on a weekly basis. For most of the measured elements we are 95-100% compliant with performing those processes identified to decrease the risk of SSI. The final and most important measurement is that there has been a decrease in the number of SSIs since the implementation of the CVQA checklist.
In addition to the above, select members of the team are now holding CV SSI huddles for review of any cases of SSI. These huddles help to determine which processes and areas of improvement could be further explored to help decrease the risk of SSI. Any issues uncovered are then brought back to the team for further investigation, discussion and correction.
Areas who are working so diligently to help with this important patient safety initiative include PATC, PACU, POLA, Operating Room, Cardiovascular Services and Medical Staff, C8, B9I, B9E, B10I, N10, C10, B10E, Infection Control, Research Administration and Quality Management.
View our latest Surgical Site Infections/Antibiotics Before Surgery Performance Measures.
Bloodstream Infections ... Zero in Sight!
March 3, 2011
January had zero infections for all ICUs and we are now approaching 10 months with an average across the entire organization of less than one BSI per month (down from approximately 4 per month in 2008. In fact, Bliss 11I recently celebrated 204 days with no BSIs.
This is as a result of the resolve and focus of the BSI Action group and new workflow instituted in all of the ICUs.
Upcoming innovations we are evaluating in preventing BSIs include 2 new trials in the ICUs this month:
- A 3M Tegaderm securement dressing for all intra-jugular central lines and
- An alcohol soaked end cap to aid our “scrub the hub” initiative designed to ward off environmental bacteria that may contaminate our patients.
We are also to standardize the training and education for all clinicians who insert central lines at Hartford Hospital annually through a structured program beginning with our state of the art Simulation Center.
View our latest Catheter-Related Bloodstream Infections Performance Measures.
Our Commitment to Hand Hygiene
April 9, 2009
In the month of November we demonstrated 100% compliance with hand washing before and after patient care as well as 100% respect for isolation precautions. However, we have recently seen a downward trend in compliance with hand hygiene and isolation precautions. We know that Hartford Hospital has and can continue to represent best practice.
We must remember that hand hygiene is one of the most basic ways that we can protecting our patients from hospital acquired infections. As with our success in preventing patient falls, this takes everyone’s support. We are reviving our approach to this most basic patient safety action and our success is up to you.
Here are some of the measures being implemented to assist us achieve this goal:
- New signs have been created to be posted outside of rooms with patients on precautions that are easier to read with fewer words and clear messaging through pictures. These will be distributed beginning on May 1.
- Each clinical area that provides audit data will receive monthly progress reports on how well they are performing against other units.
- Infection control team members will perform 5 hand hygiene audits each month.
Infection Control is working with Volunteer Services to enlist their support in monitoring hand hygiene, similar to what has been done in fall prevention.
- We are exploring opportunities to revisit the use of screensavers and television screens throughout the hospital to reflect our commitment to this initiative.
- Hand Hygiene will be placed on upcoming Work Group and Department Meeting agendas.
- Increased rounding focused on hand hygiene.
- Infection Control staff will host a PURELL DAY in the cafeteria on May 5th.
Our goal is 100% compliance with best practice in hand hygiene and complete respect for isolation precautions.
View our latest Hand Hygiene Compliance Performance Measures.
View a video on the proper technique for washing your hands.