2017 Annual Nursing Report

EXEMPLARY PROFESSIONAL PRACTICE

Pursuing Clinical Excellence in 2017 Clinical Excellence was a major focus for our facility to decrease healthcare-associated infections, healthcare-acquired conditions, and mortality, and to maintain compliance with core measures (90% expectation). The “Aim for Zero” campaign was set as our roadmap to success. The Infection Preventionist’s role was one of surveillance, performance improvement to reduce HAIs, acute response to potential or actual outbreak investigations, education training for healthcare personnel and patients, public reporting, and regulatory and accreditation activities. Kim Mecom’s role as infection preventionist had the expectation for daily rounding with concurrent feedback to staff to promote and communicate effective implementation of infection-control strategies.

QUALITY DEPARTMENT Front row left to right-Janice Cheverton, Marsha Mann, Marcia Mason, Debi Potter Back row left to right-Brenna Williams, Ashley Day-Costa, Kim Mecom, Katina Gee, Elizabeth Ryan, Christie Jackson

So—how did we do?

2016

2017

Improvement Noted

Hand Hygiene

93.8%

94.25%

YES

CHG bath

84.3%

89.16%

YES

Mupriocin

91.3%

93.4%

YES

MRSA

0

0

N/A

VAE

13.81

15.97

No

CDIFF

5.82

7.33

No

CLABSI

0.82

1.58

No

CAUTI

0.716

1.54

No

SSI Colon

6.89

0

YES

SSI Hyst

0

0

N/A

HACs

2

2

N/A

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