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Board hears quality update: infection metrics favorable but Cerner implementation delays some reports, hand‑hygiene and barcode adherence below targets
Summary
Quality leaders reported no recent healthcare‑acquired infection events, introduced two new hires, and said some national reporting metrics (cesarean and sepsis rates) are delayed while Cerner report validation continues; hand‑hygiene and barcode medication scanning rates remain below goals.
Hospital quality leaders summarized recent performance and new staffing and said some metrics remain delayed while the organization validates data after a Cerner implementation.
The hospital introduced two new hires to the board: Benita Orderedang, RN clinical risk manager and patient safety officer, and Tracy Bynum, infection preventionist. The quality dashboard presented to the board is intended to mirror national reporting expectations (Leapfrog and CMS) and to show performance on patient safety, infection control, medication barcode scanning and patient experience metrics.
Quality staff reported no healthcare‑acquired infection events in the reporting window (several months without an event), and that the falls‑with‑injury metric had been at 0% for more than 365 days. However, hand‑hygiene adherence was reported at about 90% for January and February and below the internal target. The presenter said the dashboard currently reports "adherence scores" (percentage of correct hand‑hygiene actions) and that an observation metric required by Leapfrog will be added to future quality reports to increase transparency.
The barcode medication administration rate was reported at 92% and rising; the hospital’s goal is 95%. Quality staff said enhancements to Wi‑Fi and pharmacy monitoring of barcode issues are already in place to improve scanning rates.
Board members asked why cesarean and sepsis metrics were not available. Quality staff and the compliance team explained that after a major electronic medical record implementation the organization must validate a full quarter (three months) of charting before reports can be relied upon. That validation process — and coding reconciliation — is expected to be complete in the June–July timeframe, at which point the hospital intends to reintegrate those metrics into reporting and trend analysis.
Quality committee members also invited board members to join the quality committee; the board discussed meeting scheduling conflicts and agreed at least one clinical board member would try to attend.
The board moved and approved the quality report.
Ending: Quality staff will add Leapfrog observation data to the dashboard, continue Cerner validation work, and return to the board with updated metrics as they become available.
