Page 79 - Flipbook January Board

TOPIC DISCUSSION/CONCLUSION RECOMMENDATIONS/
ACTION/FOLLOW UP
/RESPONSIBLE PARTY
III. Infection Control – Andrew Klee provided report on Infection Control. Recommendation to
Copy of presentation • Reviewed hospital acquired infection data for fiscal year 2019. discontinue the use of
attached to official • Nurse driven c.diff decision making flowchart implemented in August 2018. contact precautions for
minutes • Reviewed c.diff root cause analysis tool and identified areas of opportunity. MRSA colonized patients
• Reviewed hand hygiene departmental compliance rates. was well received by

• Reviewed catheter-associated urinary tract infection data. committee members.
• Discussed Foley catheter removal opportunities. Proposed change to be
• Alternative product for female Foley to be trialed on 6 SW. presented at Medical
• Discussed a proposed change to isolation precautions for patients with MRSA Executive Committee in
January 2019 for approval.
colonization.

IV. Rehabilitation Susan Sinay provided report on RPH Rehabilitation Services. Informational
Services – Copy of • Systemwide expansion of Lymphedema services by certified personnel.
presentation attached to • New simplified breast cancer educational booklet created.
official minutes • Dyad nursing units received enhanced mobility training for Care Partners.
• Reviewed key quality metrics dashboard.
• New report created in EPIC for nurse managers to view patient mobility levels,
ambulation time/feet, and time spent in a chair.

• Areas of opportunity identified for cardiac rehab patients including functional
capacity improvement, blood pressure control, and improvement in depression.
• Low inventory of high back chairs and recliners is negatively impacting patient
mobility. Administration has committed to purchasing additional quantities to
improve patient outcomes.
V. 7 NW (Joint Camp) – Willow Bronson-Golay, RN provided report on 7 NW / Joint Camp Nursing Unit. Informational
Copy of presentation • Collaboration with orthopedic physicians to complete several quality improvement
attached to official projects including:
minutes o Standardized dressings
o Hypotension protocol
o Bowel regime

o Updated ortho order sets
o Drain usage and order set for care and removal
o Reducing length of stay for joint replacement patients
• Reviewed quality metrics dashboard.
• Current quality projects implemented to improve compliance rates for hand
hygiene, PRN pain reassessments, discharges by 1100, and physician rounding.
• Reviewed regulatory findings. Weekly chart audits for nursing assessments
currently at 100% compliance.
• Blanket warmer removed from unit as joint replacement patients cannot utilize.

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