About Us - Act 53 Hospital Community Report - Quality Improvement

Copley Hospital’s Quality Improvement Goals

PROJECT NAME: Medication reconciliation

TIME FRAME: January 2005 and ongoing

DESCRIPTION: Accurately and completely reconcile medications across the continuum of care.

PROBLEM: A complete list of all medications being taken by a patient may be difficult to obtain in a timely fashion on admission.

GOALS:
     a. Develop a process for obtaining and documenting a complete list of patient’s current medications upon admission
     b. Communicate a complete list of patient medications to the next provider of service on transfer to another setting, service, provider or level of care

MEASURES: Compliance with uniform documentation of all patient medications.

INTERVENTION:
The patient’s current medication list is obtained on admission.  This list is verified by nursing.  The discharge summary done by the physician details all medications the patient will have at discharge.
 
EVALUATION PROCESS: Quarterly chart review and education


PROJECT NAME: Infection reduction

TIME FRAME: January 2005 and ongoing

DESCRIPTION: Reduce the risk of health care-acquired infections.

PROBLEM: Health care acquired infections lead to increased length of stay, costs, and may put patients at a higher risk for other complications.

GOALS: Eliminate health care acquired infections.

MEASURES: Nosocomial infection rates.

INTERVENTION:
Comply with current CDC hand hygiene guidelines. CDC guidelines promote the use of alcohol based hand sanitizers.  Our Infection Control Practitioner has overseen the installation of dispensers in the corridors of all patient care areas.

EVALUATION PROCESS:
Monitor use and replacement of hand sanitizer; monitor hand washing by direct observation.


PROJECT NAME: Caregiver communication

TIME FRAME: January 2005 and ongoing

DESCRIPTION: Improve effectiveness of communication among caregivers.

PROBLEM: Incomplete or misunderstood communication may lead to medical errors which may be avoided through standardized methods

GOALS: Improve communication through standardized methods

MEASURES: Read back rate, “do not use” abbreviation occurrences, unreported critical lab values

INTERVENTION:
     a. “Read back” process for verbal orders by person receiving the order
     b. Standardize abbreviations, including a “do not use” list
     c. Measure, assess and, if appropriate, take action to improve the timeliness of reporting critical test results and values
     d. All values defined as critical by the laboratory are reported directly to a responsible caregiver within times established by the laboratory
 
EVALUATION PROCESS:
Quarterly chart reviews done to assess adequacy of education and compliance with interventions