Aware of our performance improvement opportunity in this area in that . . .

We have undertaken an enterprise-wide educational effort addressing the frequency and severity of nosocomial infections within our patient population and potential impact of performance improvement practices related to the absence of or inadequate hand washing, within the 12 months prior to submitting this survey, as documented by meeting minutes, attendance or completion records.

Within the last 12 months prior to submitting this survey, the organization has:

performed an enterprise-wide evaluation of the frequency and severity of nosocomial infections.

submitted a summary report to administration and governance with recommendations for measurable improvement targets and further action.

For the last 12 months or more,

the organization, through ongoing evaluation, has monitored and continues to report results of measurable improvement targets related to this area to administration and governance.

Accountable to this issue as evidenced . . .

by departmental/clinical service line managers all being directly accountable for the patient safety area through documented personal performance reviews or personal compensation incentives, or other organization-specific documented evaluation review processes.

by having developed documented personal performance reviews or personal compensation plans, or other organization-specific documented evaluation review processes which now hold senior executives in addition to department/clinical service line managers accountable for this safe practice.

the organization has either a Patient Safety Officer or an Administrator who oversees organizational patient safety regularly reporting to the CEO and the Board performance improvement metrics related to this safe practice and is directly accountable for this through documented personal performance reviews or compensation, or other organization-specific documented evaluation review processes.

Invested in our ability to deal with this issue by . . .

Within the last 12 months prior to submitting this survey, conducting staff education/knowledge transfer and skill development programs as documented by meeting minutes attendance or completion records.

Our organization has:

documented expenditures on staff education related to this safe practice in the previous year.

has incorporated additional funding in the new budget.

Taking additional actions to ensure that . . .

explicit organizational policies and procedures are in place across the entire enterprise to prevent nosocomial infections due to inadequate hand washing techniques including CDC guidelines with category IA, IB, or IC evidence with routine measurement of compliance and process improvement addressing compliance within the 12 months prior to submitting this survey.

by having implemented a formal performance improvement program addressing nosocomial infections (with regular performance measurement and tracking improvement within the last 12 months) focused on hand washing techniques and compliance.

by having implemented an enterprise-wide performance improvement program for hand washing compliance (with regular monitoring and measurement of indicators within the last 12 months).

by having completed, in the last 12 months or more, a formal, enterprise-wide performance improvement program addressing all elements of this Safe Practice and Additional Specifications with ongoing monitoring and measurement and subsequent process improvement based on established targets.

Aware of OUR performance improvement opportunity by . . .

undertaking an evaluation of the frequency, severity, and potential impact of performance improvement practices on surgical site infections in our patient population within the 12 months prior to submitting this survey.

Within the last 12 months prior to submitting this survey, the organization has:

performed an enterprise-wide evaluation of the frequency and severity of incidents of surgical site infections.

completed a literature review to determine best practices.

has submitted a summary report to administration and governance with recommendations for measurable improvement targets and further action.

For the last 12 months or more,

the organization, through ongoing evaluation, has monitored and continues to report results of measurable improvement targets related to this area to administration and governance.

Accountable to this issue as evidenced by . . .

our senior executives and departmental/clinical service line managers all being held directly accountable for performance in this patient safety area through documented personal performance reviews or personal compensation incentives, or other organization-specific documented evaluation review processes.

our organization has either a Patient Safety Officer or an Administrator who oversees organizational patient safety regularly reporting to the CEO and the Board performance improvement metrics related to this safe practice and is directly accountable for this area through documented personal performance reviews or compensation, or other organization-specific documented evaluation review processes.

Invested in our ability to deal with this issue by . . .

Conducting staff education/knowledge transfer and skill development programs as documented by meeting minutes, attendance or completion records during the 12 months prior to submitting this survey.

The organization:

allocated compensated staff time to work on this safe practice.

can document expenses incurred during the past year tied to this safe practice.

has incorporated further funding for this safe practice in the next budget year.

Taking action to address this issue . . .

by having already actively implemented explicit polices and procedures for documented risk assessment and prevention plans for reducing surgical site infections including:

appropriate use of antibiotics

appropriate hair removal

postoperative glucose control

postoperative normothermia

by having implemented a formal performance improvement project/program (with regular performance measurement and tracking improvement within the last 12 months) addressing reduction in surgical site infections and implementation of specific protocols as documented in the medical record including:

appropriate use of antibiotics

appropriate hair removal

postoperative glucose control

postoperative normothermia

by having implemented a clinical unit-wide, department-wide, or service line performance improvement process (with regular monitoring and measurement of indicators within the last 12 months) specific to surgical site infection prevention.

by having completed, in the last 12 months or more, a formal performance improvement program including all surgical patients addressing all elements of this Safe Practice and Additional Specifications with ongoing monitoring and measurement and subsequent process improvement based on established targets.

Aware of OUR performance improvement opportunity . . .

having undertaken an evaluation of the frequency, severity, and potential impact of performance improvement practices on central venous catheter-related blood stream infections in our patient population within the 12 months prior to submitting the survey.

Within in the last 12 months prior to submitting this survey, having:

performed an enterprise-wide evaluation of the frequency and severity of incidents of central venous line infections.

completed a literature review to determine best practices.