Executive Summary free essay sample

The Republic of India, located in southern Asia, gained independence from Britain in 1947. After gaining independence, the country became a Federal Republic (Chakrabarty 39). Because of the countries enthusiasm for democracy and its sheer size, India has been â€Å"branded as the biggest democracy on the globe† (Chakrabarty 1). Many scholars describe India’s government as a hybrid of the US and the UK because of its parliamentary system, federal set-up, and reliance on its constitution (Chakrabarty 31). Although the country is a democratic world power, it is still considered a developing country, due to its vast income inequality. India’s constitution was written in 1950, shortly after the country gained independence. The constitution calls for freedom, equality, and unity (Chakrabarty 5). India’s constitution is the â€Å"longest basic law of any of the worlds independent countries. It contains, at latest count, 444 articles and a dozen schedules. Since its original adoption, it has been amended more than one hundred times, and now fills about 250 printed pages† (Mehta). The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. 2. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. 3. Implement evidence-based practices to prevent healthcare– associated infections due to multidrug-resistant organisms in acute care hospitals. 4. Implement evidence-based practices to prevent central line– associated bloodstream infections. 5. Implement evidence-based practices for preventing surgical site infections. There are opportunities to implement and to improve on established programs for Infection Control and Prevention. Establishing and reinforcing Nightingale Community Hospital’s commitment to implement programs and improve on identifying, preventing and controlling infections will reduce cost of care while improving patient safety and education. Multidrug Resistant Organisms Current Compliance Status Patients continue to be at risk for nosocomial transmissions that are multidrug- resistant. Nosocomial transmissions did not meet the Joint Commission Accreditation standards 7 out of the 12 months. Number of MDRO Infections Rate/1000 Patient Days January 0 0 February 4 1. 5 March 2 0. 75 April 2 0. 5 May 1 0. 25 June 1 0. 25 July 0 0 August 1 0. 25 September 1 0. 25 October 0 0 November 0 0 December 0 0 Although there was a reduction rate of Mulitdrug-resistant organisms (MDROs) from February through August, the 12-month rolling rate average is 3. 2 infections/1000 patient days. The current goal set by Nightingale Community Hospital is 0. 15 infections/1000 patient days. Joint Commission Accreditation Standard Reduce the risk of health care-associated infections (2013 The Joint Commission). There are nine Elements of Performance (EPs) that are required and that have direct impact on patient care: 1. Conduct periodic risk assessments (in time frames defined by the hospital) for multidrug-resistant organism acquisition and transmission. 2. Based on the results of the risk assessment, educate staff and licensed independent practitioner about HAIs, MDROs, and prevention strategies at hire and annually thereafter. 3. Educate patients, and their families as needed, who are infected or colonized with a MDRO about healthcare–associated infection prevention strategies. 4. Implement a surveillance program for MDRO based on the risk assessment. 5. Measure and monitor multidrug-resistant organism prevention processes and outcomes. 6. Provide MDRO process and outcome data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians. 7. Implement policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms. These policies and practices meet regulatory requirements and are aligned with evidence-based standards 8. Implement a laboratory-based alert system that identifies new patients with MDROs. 9. Implement an alert system that identifies readmitted or transferred patients who are known to be positive for multidrug-resistant organisms. Corrective Action Plan Perform quarterly risk assessments of MDROs transmission and acquisition. Provide annual educational seminars to staff and practitioners regarding the transmission, reduction, control, and prevention of HIAs based on the quarterly risk assessment outcomes. Focus on family and patient education to bring awareness of reduction, prevention, and treatment of MDROs. Healthcare-associated infections (HAI) surveillance should identify the population who are of greater risk for contraction or transmission of MDROs over a 12- month period. During the monitoring period treatments and outcomes should be measured to determine the effectiveness and adherence of protocols. Monitor isolation to assess risks. Prepare quarterly reports to key stakeholder regarding HIAs monitoring, protocols, and outcomes. Review and incorporate evidence-based standards to reduce, prevent, and treat HIAs that meet regulatory standards from organizations such as Center for Disease Control (CDC), Department of Health and Human Services (HHS), and World Health Organization (WHO). Implement real-time electronic laboratory reporting that identify patients with MDROs to the respective treating clinicians and provide treatment protocols. Monitor and measure outcomes based on response time from identification to treatment, length of stay, recurrence, mortality, morbidity. Implement an alert system that identifies readmitted and transfer patients with known MDROs in order to treat and contain transmission in accordance with evidence-based standards and protocols. Central Line Bloodstream Infections (CL-BSI) and Central Line Bundle Current Compliance Status 3 out of the 12 months central line bloodstream infections were out of compliance with Joint Commission Accreditation standards. Month out of Compliance Number of CL-BSI Rate/1000 Patient Days March 1 5 August 1 5 September 1 7 Current surveillance objective goal is to achieve 90% by the end of the fiscal year. The processes used will be in accordance with the CDC. Quarterly outcomes will be presented to stakeholders with recommendations of areas for improvements where needed. 4. Implement patient and family education regarding the facts of SSI: Treatment of SSI using antibiotics. How the hospital treats and handles the prevention of SSIs. What the patient and family can do to help prevent SSIs before surgery, at the time of surgery, and after surgery. How to treat the surgical site after the patient is home. Provide written literature for the patient and family to review after the patient was seen by a practitioner. 5. Conduct an educational based on the current Joint Commission Accreditation standards review of SSI at the time of transfer to surgical service (or time of hire) and annually thereafter for surgical staff, including physicians, administrative staff, and nursing staff. Environmental Rounds Data Current Compliance Status The current Infection Control Environmental Rounds Data hospital-wide average for the previous 3 years: Bi-Annual Rounds Previous Year 1 Previous Year 2 Previous Year 3 Hospital-wide Average 82. 7% 83. 2% 86. 1% 88. 2% Environmental data includes: Infection control management Staffs’ compliance with food/drink restrictions Dust free environments Refrigeration and ice machine cleanliness and regulated temperatures Negative pressure rooms are at negative pressure Patient rooms and bathrooms are clean and in good repair Isolation cabinets clearly indicated Properly stored clean linen Ensure stagnant water is not in the hopper in the dirty utility room Accessibility of alcohol-based foam/gel Multidose vials are with expiration date Prep areas and carts are clean and remnants are properly disposed of Staff are compliant with proper hand hygiene Supplies are not expired BGM kits are clean and reagents are not expired Joint Commission Accreditation Standard 1. The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. 2. The hospital uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection. 3. The hospital implements transmission-based precautions * in response to the pathogens that are suspected or identified within the hospital’s service setting and community. 4. The hospital investigates outbreaks of infectious disease. 5. The hospital minimizes the risk of infection when storing and disposing of infectious waste. 6. The hospital implements its methods to communicate responsibilities for preventing and controlling infection to licensed independent practitioners, staff, visitors, patients, and families. Information for visitors, patients, and families includes hand and respiratory hygiene practices. 7. The hospital reports infection surveillance, prevention, and control information to the appropriate staff within the hospital. 8. The hospital reports infection surveillance, prevention, and control information to local, state, and federal public health authorities in accordance with law and regulation. 9. When the hospital becomes aware that it transferred a patient who has an infection requiring monitoring, treatment, and/or isolation, it informs the receiving organization. 10. When the hospital becomes aware that it received a patient from another organization who has an infection requiring action, and the infection was not communicated by the referring organization, it informs the referring organization. Corrective Action Plan Implement employee health surveillance of communicable disease with immunization compliance. The current goal is zero PPD conversions for tuberculosis, healthcare workers properly immunized to include a 90% rate for influenza immunization. Nonemployee health screening surveillance to be in compliance with health requirements, such as immunizations, hand hygiene awareness and compliance, prior to beginning employment or contract with the healthcare facility with a goal 95%. Implement staff awareness of blood and bodily fluid exposures and sharps safety compliance. Implement an annual review of safety devices and proper disposal of needles to prevent accidental sticks, and proper disposal of blood, bodily fluids, and waste. The current target goal is ? 1. 2 exposures per 1000 patient days. Survey sterilization compliance and review sterilization documentation and flash utilization. The current flash rate goal: