The Leapfrog Group Quality and Safety Survey



Hospital Safe Practices: Surgical Site Infection and Hand Washing


The following questions come from the Leapfrog Group’s Hospital Quality and Safety Survey. The Leapfrog Group consists of nearly 200 large private and public organizations that provide health benefits for more than 39 million U.S. employees, retirees and dependents. The Group’s goal is to improve health care safety.


The Quality and Safety Survey is based on 30 hospital “safe practices” that were identified by the National Quality Forum. Here is how the hospital responded to the questions on two of those safe practices -- Hand Washing and Surgical Site Infection:

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Safe Practice: Surgical Site Infection Prevention

Evaluate each pre-operative patient in light of his or her planned surgical procedure for the risk of surgical site infection (SSI), and implement appropriate antibiotic prophylaxis and other preventive measures based on that evaluation.

Safety Objective: Prevent person-to-person transmission of infections.



In regard to surgical site infections, our organization is:

 
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,

OR

the organization has performed an enterprise-wide evaluation of the frequency and severity of incidents of surgical site infections AND completed a literature review to determine best practices AND has submitted a summary report with performance improvement recommendations to Administration for further action.

OR

the organization commits to undertake a thorough literature review and comprehensive enterprise-wide evaluation of the frequency, severity, and potential impact of performance improvement practices on surgical site infections in our patient population with a report to administration within six months of submitting this survey.

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 personal performance reviews or personal compensation incentives,

 

OR

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.

OR

our organization commits to having our Patient Safety Officer regularly report to the CEO and Board of Directors (or sub-committee of the board) pertinent performance metrics associated with the reduction of surgical site infections within six months of submitting this survey.

Invested in our ability to deal with this issue by conducting staff education/knowledge transfer and skill development programs as documented by meeting minutes and attendance records during the 12 months prior to submitting this survey,

OR

the organization provided compensated staff time to develop standardized protocols to reduce the risk of surgical site infections and there is documentation in patient medical records of implementation of these protocols.

OR

commits to invest allocated compensated caregiver staff time to develop a standard protocol including specific risk reduction interventions (e.g., use of prophylactic IV antibiotics) and documentation of implementation of the protocols in the medical records of surgical patients within six months of submitting this survey.

 


Safe Practice: Hand Washing

Decontaminate hands with either a hygienic hand rub or by washing with a disinfectant soap prior to and after direct contact with the patient or objects immediately around the patient.

Safety Objective: Prevent person-to-person transmission of infections.



In regard to nosocomial infections related to inadequate hand washing, our organization is:

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 and attendance records,

OR

the organization has performed an enterprise-wide evaluation of the frequency and severity of nosocomial infections AND a summary report with performance improvement recommendations has been submitted to Administration for further action.

OR

the organization commits to undertake a thorough literature review and comprehensive enterprise-wide evaluation of the frequency and severity of nosocomial infections related to the inadequate hand washing. A report with a summary of the readily available improvement opportunities and recommendations in this area will be provided to administration within six months of submitting this survey.


Accountable to this issue as evidenced . . .

by departmental/clinical service line managers all being directly accountable for the patient safety area through personal performance reviews or personal compensation incentives,

OR

by having developed personal performance reviews or personal compensation plans which now hold senior executives in addition to department/clinical service line managers accountable for this safe practice.

OR

by our organization committing to assign accountability to our senior executives and departmental/clinical service line managers for this safety patient safety area through personal performance reviews or personal compensation incentives within six months of submitting this survey.

 


Invested in our ability to deal with this issue by conducting staff education/knowledge transfer and skill development programs as documented by meeting minutes and attendance records,

OR

our organization has documented expenditures on staff education related to this safe practice in the previous year and has incorporated additional funding in the new budget.

OR

our organization commits to make an explicit dedicated line item budget allocation for regular in-service educational programs within six months of submitting this survey.

 

 

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 with routine measurement of compliance and process improvement addressing adherence to policies and procedures within the 12 months prior to submitting this survey,

OR

by having implemented a formal performance improvement project/program addressing nosocomial infections (with regular performance measurement and process improvement within the last 12 months) including hand washing techniques and compliance,

OR

by having implemented an enterprise-wide performance improvement process for hand washing compliance with regular monitoring and measurement of indicators AND having implemented specific policies and procedures for this safe practice.

OR

by making the commitment to undertake a formal enterprise-wide performance improvement project/program addressing nosocomial infections that includes hand washing techniques and compliance (with regular performance measurement and process improvement) and implementing explicit organizational polices and procedures within six months of submitting this survey.

 

 





Glossary of Terms


Nosocomial Infection: A localized or systemic condition 1) that results from adverse reaction to the presence of an infectious agent(s) or its toxins and 2) that was not present or incubating at the time of admission to the hospital. (Source: Centers for Disease Control and Prevention)


Prophylactic IV Antibiotics: Drugs administered into a vein to prevent the spread or occurrence of infection.