Regardless of size, resources, and other factors, health care facilities should consistently pursue high performance. Quality measures guide hospitals in evaluating performance and determining the scope and type of interventions required to enhance performance. The purpose of this presentation is to examine data related to hospital-acquired infection rates at ABC Health. Understanding this data and its implications is crucial for stakeholders to collaborate and define the desired goal for improvement. The main presentation areas include conclusions drawn for each measure, trends, and comparisons with the national benchmark. Other areas include an outline of priority quality measures, quality improvement metric, monitoring strategies, and using data for quality improvement.
Conclusions for SSIs from Colon Surgery (SSI: Colon)
In the current practice, surgical site infections (SSIs) continue to threaten patient safety and care quality. According to McFarland et al. (2023), SSIs are the second-most occurring hospital-associated infections after urinary tract infections. As displayed in this graph, SSI: colon rates rose sharply from 2012 to 2013 before increasing steadily from 2013 to 2015. Generally, there is a threatening increase in infection rates, posing a significant risk to patients undergoing colon surgery at ABC Health. Hou et al. (2020) reported that a single incidence of SSIs after surgery can double the danger of postoperative mortality. Therefore, multimodal interventions to prevent the rising infection rates for SSI colon are crucial in the facility.
Conclusions for CLABSI
Organizational leaders should know all issues hampering care quality and increasing facility management costs. Awareness of the rates of CLABSI can help them design effective control measures and reduce costs. As shown in the graph, CLABSI rates at ABC Health during the five years are somewhat within the same range (2.234, 2.089, 3.128, 3.063, and 3.422). Despite this performance, the goal should always be providing care without an incidence of HAI. This data could imply that the present interventions for controlling CLABSI are ineffective. Therefore, a change is necessary, but intervention designers and implementers should be effectively guided by data, scientific evidence, and priorities.
Conclusions for CAUTI
Hospitals should be safe sites for patients and care providers. A reliable way of achieving this goal is to implement measures to prevent HAIs as much as possible. CAUTI infection rates data for ABC Health is encouraging since it shows a consistent decline over the five years. Such a decline implies increased patient safety, more satisfaction, and other outcomes of reduced infection rates. Musco et al. (2022) suggested that most facilities rely on care bundles to prevent CAUTI, consisting of multiple interventions to address various clinical indicators. From the data on CAUTI at ABC Health, it can be deduced that measures used to prevent CAUTI from 2011 to 2015 were effective.
Conclusions for SSI: Hysterectomy
A facility recording high rates of surgical site infections from abdominal hysterectomy (SSI: Hysterectomy) should be worried about its procedures and the standard of the care environment. As the graph demonstrates, SSIs from abdominal hysterectomies at ABC Health increased steadily from 2011-2015 (1.148, 2.132, 2.094, 3.697, 4.608). Although there was an insignificant decline during the 2012-2013 period, overall data demonstrates a high-risk area since there has been no considerable decline over the years. Shigematsu et al. (2022) associated high infection rates after abdominal hysterectomy with prolonged operative time (lasting over 3 hours), excess blood loss, and the general condition of the patient. Therefore, examining these risk factors could help ABC Health to prevent further increases in the rates due to the resultant harm.
Trends Over the 5-Year Period
Hospitals should use quality measures to guide performance improvement. As the data shows, the rates for SSI colon have steadily increased in the past three years. CLABSI rates also reveal some increment in the same period, which is different for CAUTI, whose rates have declined. However, there is no data to allow a comprehensive analysis of CAUTI. SSI: hysterectomy rates are also on a gradual increment in the last three years. From these trends, it is obvious that risk factors that increase HAIs at ABC Health were high from 2013 to 2015. If not effectively controlled, there is a likelihood of recording similar or worse data after 2015.
Comparison with the National Benchmark: SSI Colon
Hospitals should always weigh their performance internally and externally. Willmington et al. (2022) underlined the importance of nati
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