As we come to the close of 2022, we want to provide you with some “house-keeping” suggestions as we go into another year. We encourage you to pause and reflect on the great care you give to your patients and spend time with family and friends as we head into the new year.
|Review the performance expectations that are included in your organization’s clinical contracts. There may be opportunities to update them to reflect changes in your expectations of service. Give thought to the current environment and develop new criteria of performance, perhaps around staffing, staff competence, turn around times for provision of services and Covid Vaccine status.
|Ensure that your organization’s Pharmacy & Therapeutics Committee reviews your organization’s selected list of Look-Alike/ Sound-Alike medications. Keep in mind this list should be based upon both internal errors and near-misses that occurred within your organization, along with lessons learned from current literature. The Institute for Safe Medication Practices (https://www.ismp.org/) contains very helpful information.
|Have Pharmacy, Nursing and Medical Staff teams review your order sets, protocols and/or standing orders to ensure that they reflect the most current evidence -based medicine. Be certain to document these reviews inclusive of the evidence used to substantiate the practice selected.
|CMS requires that every department/service providing care, treatment or services within the health care organization participate in the QA-PI Program. Review your QA-PI program reporting schedule to ensure that any new department/service has selected performance measures and is scheduled to report on their performance at your QA-PI Committee.
|Inspect all instrument tape used by the Sterile Processing Department to identify what instruments belong to what instrument trays or providers. This should be done every time an instrument is reprocessed. By starting off the year with new, properly applied instrument tape, reprocessing time will be shortened, and the potential for bacterial growth under and around the tape will be minimized. The IFU will provide staff guidance for applying the tape to the instruments. See our newsletter article entitled, "Let’s Talk Sterile Processing."
|Observe, on Environment of Care rounds, if all units that have blood, formalin, and other hazardous chemicals, have appropriate and complete spill kits readily available to them. Identify the location of these kits and educate staff on their location and how to use them.
|Review all OPPE/FPPE measurement indicators to ensure that they are appropriate for the specific specialty that the provider is practicing in. Update these measurement indicators if trends are seen in any specialty area in order to minimize adverse events from occurring and ensure quality patient care. Remember that practitioners that work both on the inpatient and outpatient services need to have indicators that cover both care settings.
|Educate your staff on what a contact or wet time is for disinfectant wipes and show them where to find the information on the container. Explain to them why this is so important. You might want to consider a competency for their file. Let the staff know that if the disinfectant does dry on the surface before the contact time is reached, they need to reapply the disinfectant using a clean wipe to ensure that the contact or wet time is met. Observe staff performing the disinfection process to ensure that staff are following the steps for disinfection correctly and re-educate as often as needed.
|Review all thermometer, timer and other measurement device instructions for use to determine if they require calibration and that your devices are current in their maintenance. Consider including these devices in your biomedical maintenance schedule program to ensure calibration is not missed.
|Review your documentation related to titratable medications. Do the orders provide clear instruction to staff on how to titrate the medication? Are your staff documenting real time and according to the provider order? Discuss with your staff if the use of block charting for documenting titration would be more supportive of patient care with hemodynamically unstable patients. Consider developing an organizational block charting policy with the required elements. See The Joint Commission FAQ on Block Charting.
|Download AHRQ’s manual Reducing Healthcare Carbon Emissions: A Primer on Measures and Actions for Healthcare Organizations to Mitigate Climate Change to determine how your organization can reduce their impact on the environment. This guide was developed in cooperation with the Institute for Healthcare Improvement to help reduce the carbon footprint of healthcare. Organizations can save significant money with carbon reduction and improve the environment.
|Review your connected medical devices for Cybersecurity vulnerability. Use the FDA resource page for guides, current alerts and training to ensure your devices are safe from cyber threats.
From the staff at Courtemanche and Associates!
We wish you a safe and productive New Year and look forward to serving you in 2023.
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