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Hand Hygiene Quality Improvement

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Hand Hygiene Quality Improvement

  1. 1. ASSIGNMENT #1 DIRECTIONS AND RUBRIC Each team will pickone of the following safe processeslistedbelow: 1. Hand hygiene 2. Fall precautions 3. Universal Precautions:2identifiers 4. 7 patientrightsof medicationadministration 5. 3 medicationchecks 6. Isolationprecautions: contactisolation,dropletisolation,airborne(pickone) 7. Sterile technique Researchevidence basedpractice recommendationsrelatedtothe practice. Developa TexasA&MHospital Campaign to improve compliance withthe evidencebased practice recommendations inNUR313 Fundamentalsof Nursing Students. Step #1: Complete the followingworksheet. Refertothe Institute forHealthcare Improvement(IHI) page PDSA asneeded: http://www.ihi.org/resources/pages/tools/plandostudyactworksheet.aspx Is thislinkedtoJointCommissionNational PatientSafetyGoal? Yes No NPSG07.01.01 PDSA AIM: What is your team trying to accomplish? Increase hand hygiene compliance Measure: How will you know that a change is an improvement for this PDSA? Compare the number of times the nurses sanitize upon entering and exiting the room and compare it with previous numbers obtained before the implementation of the tracking system Change: What changes can the team/individual make that would result in an improvement? Implement an automatic alcohol hand sanitizer dispenser that also logs the number of times a nurse has entered the patient’s room as proof of hourly rounding. The system would not only measure the total of times the nurse has entered the room via a sensor on the nurses’ badge but also whether they have sanitized upon entry and exit Testing Change Plan What isthe planforthis improvementevent? Whatare the objectives? Whatdoyou predictwill happen? What is your plan to carry this out? Who? When? How? Where? What is the evidence base for this PDSA?  Record the number of times the nurses sanitize upon entering and exiting patient’s rooms.  Implement the new sanitizing log systemand record data for a period of 6 months to determine if hand hygiene compliance improves.  We predict that because the system is the nurses’ proof of hourly
  2. 2. ASSIGNMENT #1 DIRECTIONS AND RUBRIC rounding, compliance with hand hygiene will increase. The evidence base for this PDSA is that alcohol based hand sanitizers have been found to be more effective than washing hands with soap and water (CDC). Do Carry out the plan. What problemsoccurred? Doesyourteamhave any otherideas?’ Some of our sensorsdidnotwork; nursesfoundaway aroundthe system.Anotheridea our teamhad was touse a “secretshopper”systemsosomeone iswatchingthe nurses to determine if theyare followingthe new protocol. Study For thisproject,whatdata wouldyouanalyze? Doyoufeel itwouldbe possibleto meetthe predictionmade earlyoninthe project? We wouldanalyze the numberof timesthe nurse usesthe handsanitizerwhenentering and exitingthe roomversusthe numberof timestheydonot.We wouldthencompare thisdata to previousdatacollectedbefore the implementationof the new system.We do feel thatwe wouldbe able tomeetthe predictionmade earlierinthe project because oursystemholdsnursesaccountable. Act If you were todo thisprojectfor anothercycle,whatchangeswouldyourecommend for the nextcycle? If compliance were still low afterthe firstcycle of ourstudy,we wouldimplementa “secretshopper”systeminwhichafake nursingstudentwouldfollow the nurse Step #2 Develop aposterpresentationforthe studentsinNUR313 Fundamentals inNursing. The campaignpostershould addressthe following:  Scope of the problemandeffectsof breakdownonpatientpopulation.  Linkbetweenstrategyand improved patientsafety.  Informationonsource of evidence basedpractice.  Informationonimprovementstrategy/campaign/initiative plan.  Anylinkto National PatientSafetyGoals. Poster:  References  Team Members The worksheetand posterare due by 2/28/2017 at 0900. The worksheet,and postershouldbe submittedtogincether. An exampleposterwill be presented in class and posted in the Assignment#1 folder. An exampleworksheetis partof this document. (seebelow)
  3. 3. ASSIGNMENT #1 DIRECTIONS AND RUBRIC Is thislinkedtoJointCommissionNational PatientSafetyGoal? Yes NPSG07.01.01 PreventInfection PDSA AIM: What is your team trying to accomplish? Reduce infection risks for patients caused by pre-operative shaving of the surgical site instead of clipping in the OR. Measure: How will you know that a change is an improvement for this PDSA? Currently only about 50% of patients have a shave prep versus a prep with surgical clippers. QI nurse will audit pre-op and operative records for methods of surgical site skin prep. Change: What changes can the team make that would result in an improvement?  Update P&P on the surgical site prep to state “Surgical sites will be clipped with surgical clippers as needed prior to surgery. Surgical sites will not be shaved.”  Surgery stock room will only stock clipper blades and OR’s will be stocked with rechargeable clippers and disposable, single use clipper blades.  Hospital will develop and begin a “Clip, don’t nick” initiative to raise awareness of the new policy and procedure related to surgical site preparation.  All healthcare workers working with surgical patients (scrub techs, nurses, surgeons, anesthesiologists, etc.) will be checked off on new procedure. Testing Change Plan What isthe planforthis improvementevent? “Clip,Don’tnick”campaign. Whatare the objectives? To increaseawarenessabouttherisk forcontamination associated with
  4. 4. ASSIGNMENT #1 DIRECTIONS AND RUBRIC shaving patientspriorto surgery and improvecompliancewith evidencebased practice recommendations related to surgicalsite shaveprep. What do you predictwill happen? The compliancerate will improveto greater than 90% in 3 months. What is your plan to carry this out? “Clip, Don’t nick” initiative to include …… Who? Hospital education department staff and administration. When? Campaign to start 9.10.16 How? In-service meetings, newsletters, e-mail blasts, posters, online PPT presentation. Where? OR. What is the evidence base for this PDSA? CDC, APIC, Texas Medical Association Do Carry out the plan. Interventionwillbe avoice-overPPT(10slidesorless) ore-Poster. What problemsoccurred? Lackof knowledgeon how to create e-poster. Doesyour teamhave any otherideas? We feel compliancewould improvewith a see one-do one- teach one method butthisis notwithin outteam’scontrol. Please see mockPPTpostedone-campus. Study For thisproject,whatdata wouldyouanalyze? Ratedocumentsshavepreps. Doyou feel itwouldbe possible tomeetthe predictionmade earlyoninthe project? Yes. By limitingoptions(removingrazors) andprovidingeducation“Clip,Don’tNick”campaign. Act If you were todo thisprojectfor anothercycle,whatchangeswouldyourecommend for the nextcycle? Dolive presentations nexttime sothere istime forQ&A. References: ……. Please submit…………………………. Author.(year).Title. Retrievedfrom…..
  5. 5. ASSIGNMENT #1 DIRECTIONS AND RUBRIC RUBRIC Point Available Points Awarded PDSA Worksheet: Worksheet was complete and included a clear aims, measures, and changes. Plan and implementation were clearly described. Strategy to study and acton improvement in the future was addressed. o Worksheet fully discussed all 7 elements – 4 points o Worksheet discussed 6 components or partially discussed 7 elements – 3 points o Worksheet discussed 5 components or partially discussed 6 elements – 2 points o Worksheet addressed 3-4 components or partially discussed 5-6 components - 1 point o Worksheet addressed 2 or less components or partially discussed 3-4 components – 0.5 point o Worksheet not submitted – 0 points 4 points PDSA Improvement Poster. The presentation addressed the following:  Scope of the problem and effects of breakdown on patient population.  Link of improvement strategy to improved patient safety.  Information on sourceof evidence based practice.  Information on improvement strategy/campaign/initiativeplan. o Met addressed all 4 components listed above. – 4 points o Met addressed all 3 components listed above – 3 points o Met addressed all 2 components listed above – 2 point o Met addressed all 1 or less of the components listed above or no projected submitted – 0 points 4 points Evidence Based Information presented and cited. o Information provided was evidence based, accurate,and presented in original,teamdeveloped format. Sources appropriately cited usingAPA format – 0.5 points o Some of the information presented was evidence based, accurate, and/or presented in an original,teamdeveloped format. Sources cited without APA formatting – 0.25 point o 22 – 0 points 0.5 point Grammar and Professional Presentation: PDSA presentation was professional and educational. Poster was organized and free of spelling and grammatical errors. o Poster was professional, organized, and educational. Minimal 1 point
  6. 6. ASSIGNMENT #1 DIRECTIONS AND RUBRIC grammatical/spelling errors [0-3] – 1 point o Poster was unprofessional, unorganized, or not educational. Moderate grammatical/spelling errors [4-6} – 0.5 points o Poster was unprofessional, unorganized, or not educational. Large amount of grammatical/spelling errors [7 or more] – 0 points Deadline: o Project submitted by deadline – 0.5 point o Project not submitted by deadline but within 24 hours of deadline – 0.25 points o Project was submitted 24 hours or more after deadline – 0 points 0.5 point PointsReceived: __________/10 Comments:

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