Champion Handwasher

Hospital Campaign
Corrective Action Plan:
Work S.M.A.R.T.E.R.,
not harder
Approach
 Self Help Process Flow
• A Tool that will facilitate engaging others in your
organization to initiate the “culture of safety” that will
benefit both Patient Safety and the bottom line.
• Teaching Administration and Clinicians to row in the
same direction.
• We want to help you Tap into the Root causes of the
systemic disease, which will lead to irreversible damage
to the growth and appearance of your health system, if
allowed to fester.
• Feeding the Roots of your system will always give better
growth and blossoms and the ability to fend off unknown
or unexpected diseases that will affect your plant.
Improving the Culture of Safety
• Begins with effective communication
strategies and a road map.
• A road map will reduce your chances of
NOT arriving at your destination.
• If you have a destination and a map, it is
easier to arrive at your goal.
• Having the correct tools will make
completion of the project easier.
Working SMARTER not Harder
• In the compressed time and stressful
environment (both work and home), we no
longer enjoy the luxury of available meeting
exchanges.
• Thinner margins reduces the availability of
worker participation, while operating the
business, hence requires innovation to achieve
the best result.
• Templates and standardization of process is one
secret.
 What Causal Factor and Root
Causes are you Fixing with this
Corrective Action?
• Specific:
• Measurable:
• Accountable:
• Reasonable:
• Timely:
• Effective:
• Reviewed for Unintended Consequences:
 Specific:
• What exactly do you want them to do for this
Corrective Action? Reduce HAI incidence in our
hospital. SSI are the 4th leading cause of Hospital
deaths according to CDC.
• Any policies, procedures, tools, PPE, etc. needed?
JCAHO policies, CDC guidelines, NPSF goals,
• Specific Conditions required? Identify opportunities to
limit transfer of infection from person to person, object
to person, self contamination.
 Measurable:
• How can someone determine if Corrective
Action was implemented? (called
Verification). Review reported data on
infection incidence by date, site and type.
• Who will verify Implementation? CHHC
Officer or Coach
• Have they been notified? Yes/no
• Set Verification due date. 6 months later
 Accountable:
• Who is responsible to implement Corrective
Action? A Coach in each department.
• Have they been notified?
• Do they have the resources they need for
implementation? No. They need the Tool Kit and
backing of administration to roll out on their unit.
Infection Control says we already have a
program while patient safety doesn’t believe it is
sufficient to reduce incidence of HAI.
 Reasonable:
• Does this make good business sense?
• If not, why do it?
• If yes, how? There is a JCAHO requirement to report HAI that affected life
or limb. Risk Management predicts it will lessen our liability exposure.
Marketing predicts it will benefit our Public Image (hence business,
admissions) that we are proactive in protecting the patients as there is
legislation in other states to list this data publicly.
• What is return on investment? To initiate the CHHC CAP is $25,000. Two
staff members FTE is $150,000. The projected savings: $50,000 annually
to a rainy day fund for one HAI pay out/10 years. Complications from one
surgical site infection is $15,646, according to CDC Burn Prevention.
500,000 SSI nationally per year with 5,000 hospitals equals 10 per site is
$156,460 annually. More admissions per year 10 to 100 to 200? When the
CMMS pilot is rooled to “cost” the hospital $XXX for the total expense of
caring for the infectious disease complications that occurred while
hospitalized, estimated at $6 billion for MRSA alone is $1 million per
hospital annually.
• What is Cost/Benefit ratio?
5
The burden of healthcare-associated
infections, in terms of human suffering
and cost, is huge and can be
significantly reduced through improved
hand hygiene.
Determine the best systems to support
hand hygiene in health care.
Educate caregivers.
Provide the necessary materials and
equipment for hand hygiene.
Measure and provide feedback to
caregivers about their compliance.
Provide reminders about the need for good
hand hygiene.
Facilitate a culture of safety and hygiene.
 Timely:
• What is due date for Implementation?
• If Implementation is more than a day
away, what are you going to do in the
mean time to deal with this hazard?
 Effective:
• Explain how this Corrective Action will fix
the Root Causes. ( called Validation).
• How will you measure to see if it worked?
• Who will validate that CA fixes problem?
• Have they been notified?
• Set Validation due date.
 Reviewed for Unintended
Consequences:
• Did the departments who have been affected
by the Corrective Action evaluate it for
unintended consequences?
• Who reviewed it?
• Date of review:
• Did they find that this Corrective Action could
cause any problems?
• If yes, what and how will you eliminate or
reduce?