1. Infection Prevention Quality Plans QI Showcase - April 13, 2011 Barbara Dumont, RN, CPHRM St. John’s Lutheran Hospital Libby, Montana

2. Challenge How could we raise awareness hospitalwide to improve our safety culture and infection prevention practices? Our Quality Committee decided to choose Infection Prevention as our global goal and all departments were expected to address this in their quality plans for FY2011.

3. Quality Plans Each clinical and non-clinical department met the challenge and developed infection prevention goals.

4. Hand Hygiene World Health Organization’s “5 Moments of Hand Hygiene” surveillance

5. Hand Rub Hand rub and sanitizer use surveillance

6. Pig Pen Dietary posted the Pig Pen picture and pointed to it when staff did not do a 20 second hand wash – they used a timer

7. Flu Vaccine: Seasonal influenza vaccine compliance to include either receiving the vaccine or signing the declination form

8. Personal Protective Equipment Staff received education on PPE or reviewed where to find PPE and when to use it. Staff were observed for using PPE properly. Plant ops monitored their staff wearing gowns when entering the surgery area.

9. Central IV Lines Our CL policy had been revised the previous year, which included changing from alcohol prep to ChloraPrep. New hub caps were purchased that have 70% isopropyl alcohol (IPA) in them to decrease infection at the hub.

10. Equipment Sanitizing Imaging sanitized exam rooms MM developed a policy to decontaminate devices prior to inspection, service or repair Use of blood pressure cuff disposable covers

11. Environmental Cleaning EVS monitored cleaning using a marker pen and blacklight. Office staff sanitized doorknobs when someone entered who had a cold.

12. Education Infection prevention education is included in our annual employee safety education through Healthstream online.

13. Outcomes Hand Hygiene goals 90-100% Overall = 89% compliance (ranged from 68%-100%) Flu Vaccine: 87% compliance with staff receiving vaccine. 100% overall with either receiving vaccine or signing declination form.

14. Outcomes continued…. Personal protective equipment Thresholds 85-100% Central IV line infection rate Threshold < 5% Equipment sanitizing Thresholds 90-100% 97% compliance 2.94% 91% compliance

15. Outcomes continued…. 2010: IP staff education using an all day safety training format Threshold 100% 2011: IP Healthstream online education Threshold 100% by June 30, 2011 Attendance 100% Currently at 68% completion rate with 2 ½ months to go

16. FY 2012 Hospitalwide Quality Goal Each department will develop a unit specific LEAN or similar type project Sample of topics chosen so far: 1. EVS: Patient discharge process 2. Pharmacy/Nursing: Medication reconciliation 3. Dietary: Wasted meals of discharged patients

17. Questions? Thank you!