copy of performance measure kebidanan

7/25/2019 Copy of Performance Measure Kebidanan

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Performance Measures-OBGYN

J F M A M J J A S O N

1 Primery Scsetelah gagal dalam proses lahir normal

2 Primery SC pada fetal disters3 lahir normal setelah SC

4 Kegagalan melahirkan normal setelah SC

5 The delivery of an infant by planned repeat Cesarian Section eighing 25!! grams"

# The delivery of an infant by planned repeat $nd%ction of labor eighing 25!! grams"

& 'clampsia

( The in)hospital initiation of antibiotics 24ho%rs or more after term vaginal delivery"

* '+cessive ,aternal blood loss e+cept ith abr%ptio placenta-placenta previa as evidenced

by either a red cell transf%sion. a hematocrit less than 22 or a hemoglobin less than &

or a decrease in hematocrit of more than 11 or of hemoglobin more than 3"5

* / ,aternal length of stay more than 2 days after 0aginal elivery

1! / ,aternal length of stay more than 3 days after Cesarian Section

11 / ,aternal readmission ithin 14 days of delivery

12 / ,aternal death %p to and incl%ding 42 days post part%m"

13 eaths of infants-fet%s eighing 5!! grams or more. s%b)categorised by in)hospital

neonatal deaths. pre)part%m stillborns and intr)part%m stillborns"

14 The delviery of an infant eighing less than 1(!! grmas in a hospital itho%t a $C

15 The transfer of a neonate to a $C at another hospital"

1# /n apgar score of 4 or less at 5 min%tes in live born infants ho eigh more than

1!!! grams and less than 25!! grams"

1& The diagnosis of a massive aspiration syndrome

1( The diagnosis of a birth tra%ma s%bd%ral and cerebral hemorrhage. fract%res.in%ries to nerves. spinal cord. r%pt%re of organs6

1* /n infant eighing more than and e7%al to 25!! grams. having a clinically apparent sei8%re

prior to discharge from the delivery hospital. or apgar score of 4 at 5 min%tes or re7%ires

admission to the $C for more than 24 ho%rs


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Performance Measures - Department of Medicine

1 ,ortality 9evie2 Transfer to another ac%te facility

3 se of Cons%ltant for Chronic stable condition"

4 ,ore than 3 Cons%ltants

5 :ail%re to call Cons%ltant hen diagnosis is not knon or patient is not responding"

# nplanned transfer to Special Care nit

& Code ;l%e 'val%ation

( o Code

*

Chronic ?eart :ail%re

Pne%monia

rinary Tract $nfection

Thrombolytic Therapy in patients ith ac%te ,$

12 evelopment of Pne%monia in patients treated in Special Care nit

evelopment of $nfections related to the %se of intra)vasc%lar devices in Special

Care nit and efinitive @bservation nit"

13 /ppropriateness of >

a" Colonoscopy

b" pper Aastrointestinal 'ndoscopy

c" 'ndoscopic 9etrograde Cholangiopancreatpgraphyd" ;ronchoscopy


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Performance Measures- Department of Surgery

1 o Specimen hen specimen is e+pected6

2 Significant discrepancey beteen pre)op and pathological diagnosis3 o gross and-or microscopic diagnosis hen s%ch is e+pected"

4 :ails approved medical necessity criteria for invasive proced%re hether or not the

removal of a specimen as the intent of the proced%re"

5 Cancellation of s%rgery after ind%ction"

# nplanned hospital admission from o%tpatient s%rgery %nit"

& Transfer to another ac%te care facility

( @peration for removal of foreign body left in operative site"

*


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23 Post)operative symptoms only6 at discharge

& Temperat%re 1!! oral6 1!1 rectal6 degrees farenheight ithin 24 ho%rs prior discharge"

( :ebrile ie> 1!3degrees :arenheight)oral6 at leasst once daily for more than *# ho%rs

* ?ospital inc%rred adverse incident e+cept parental carelessness-inattention

1! Transfer to another facility

11 n%s%al ,edical iagnosis

12 nplanned admission of an o%tpatient"


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Medical ecord e!ie" Yes No

1 is the final diagnosis recorded on the face sheet in f%ll. itho%t %se of

abbreviations-symbols"

2 Completion of a history and physical ithin 24 ho%rs of admission"

3 Presence of c%rrent physical e+am in patients chart. prior to all s%rgery %nder

Aeneral or maor regional anesthesia. e+cept for emergency operations"

4 9ecording of pre)operative diagnosis before s%rgery

5 )

/de7%ate

$nade7%ate


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Performance Measures - &a'oratory ;enchmark

1 @rgani8ational performance $mprovements

J F M A M J J A S O Na E%ality Control problems are corrected ithin 24 ho%rs 1!!F

b Timeliness of res%lt reporting>

1 9es%lts of all :;S to be ready ithin 2 ho%rs 1!!F

2 9eference lab res%lts to be ready ithin 4( ho%rs !F

3 /ll stat lab ork reported ithin one ho%r from time

of lab receipt to time of phone report"

4 Panic val%es are do%ble checked and called"

5 Proficiency testing and training for Gpoint of careG lab

11 ,edication se

a Therape%tic dr%g eval%ation dras coincide appropriately

ith dr%g administration" 1!!F

111 S%rveillance. Prevention and Control of $nfections

a Aloves orn hen draing blood 1!!F

b Safety clothing orn hile handling specimens 1!!F

10 ,anagement of $nformation

a =aboratory re7%isitions completed properly 1!!F

0 Patients 9ights

a Patients confidentiality is maintained" 1!!F


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Performance Measures - Pat%ology

1 @rgani8ational Performance $mprovements

a Cases referred by pathologist for peer revie *5F

b /ppropriateness of specific lab tests

1 ;lood C%lt%res *5F

2 Stat Tests 1!!F

c /greement ith fro8en section vs permanent section 1!!F

d /%topsy res%lts agree ith clinical findings" 1!!F

11 Care of Patient

a ;lood ;ank sage

1 @rdering

a6 Total %nits of blood %sed

b6 Cross ,atch H2"5

c6 $ndications for %se 1!!F

d6 Patients receiving only one %nit trend

e6 Patients receiving over 5 %nits trend

2 /dministration

a6 Transf%sion 9eaction !F

b6 $nf%sion time over 4 ho%rs 1!!F


a Pathology reports for malignancy ill incl%de>

1 ?istologic analysis

2 Arade of t%mo%r

3 '+tension of t%mo%r-margins-resection

4 =ymph node e+amined

5 =ymph node that contains evidence of metastatic disease

# Primary t%mo%r of breast. colon. l%ng ill be cancer staged"


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Performance Measures- adiology Medical (Benc%mar)s *++,

1 $mproving @rgani8ational Performance

a Peer 9evie J F M A M J J A S O N D

1 ,ammograms

2 Chests Iray in pediatrics

3 =%ng Scans

b Pne%mothora+ after invasive proced%res

11 /ssessment of Patients

a /ppropriateness of st%dies

1 ;ari%m 'nema )F of negative st%dies benchmarks 1!F62 ?$/ scans ) F of negative st%dies benchmarks 1!F 6

b 9adiology 9eport Confirmation

1 Positive radiology report vs cholecystectomy

2 'stmated fetal age vs gestational age at birth

3 Presence-absence of leiomyomata post %ltraso%nd report

4 eedle locali8ation for abnormal breast tiss%e confirmed

by pathology

c /ppropriate %se of non)ionic contrast


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Performance Measures - adiological Department Benc%mar)

1 @rgani8ational Performance $mprovement

a Canceled-9epeat proced%re J F M A M J J A S O N D

1 %e to poor preparation !F

2 Technical error !F

3 '7%ipment fail%re !F

b Complications

1 Perforations !F

2 ?ematomas !F

3 $nfectionsnosocomial6 !F

4 /spiration !F

c 9eect-repeat film rate analysis 1!F

d ,islabeled films and-or reports !F

e Timeliness of on)call Iray personnel

1 /nsered beeper ithin 15 min%tes 1!!F

2 $nto hospital ithin 3! min%tes of being called 1!!F

f @%tpatient

1 Se7%ences are correct 1!!F

2 :ormatted images are diagnostic 1!!F

h @%tpatient E%estionairre to be trended for improvements6


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Performance Measures - adiological Department (.


a Patients are screened for allergies ie> iodine. late+. medications6 1!!F

b @%tpatients re7%iring contrast media not screened for ?I

of C?:. 9enal :ail%re" !F

c 9eaction to contrast media re7%iring intervention" !F

111 ,anagement of the 'nvironment of Care

a :ilm badges orn at all times 1!!F

b 'nvironmental Safety Check 1!!Fc 9adiation Physicist e7%ipment check 1!!F

d =ead /pron check 1!!F


a Proper completion of Iray 9e7%est

1 Clinical $nformation filled o%t on re7%est 1!!F

2 ate of '+amination 1!!F

3 '+am re7%ested matches reasson for Iray 1!!F


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Performance Measures - P%ysiot%erapy (Benc%mar)s of *++,

1 Planning and Providing Care

a /ppropriateness of doc%mentation

1 $nitial 'val%ation

2 Progress 9eport

a6 aily on inpatients

b6 'very to eeks on @%tpatients

3 ischarge S%mmary

b 'ffectiveness of transfer gait training provided to patients"

Progress as noted in>

1 =evel of need for assistance grad%ally red%ced or eliminated"

2 Time red%ction in time6 to move a distance

3 istance travelled

c 'ffectiveness of hirlpool TI to patients ith cell%litis-o%nd

1 'vidence of debridement

2 iminished selling

3 ecreased pain level

4 ecreased o%nd si8e

11 @rgani8ational Performance $mprovement

a Satisfaction

1 Patient

2 Physician

111 ,anagement of the 'nvironment of Care


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a 'nvironmental ro%nds

P%ysiot%erapy-/riteria for Documentation

1 $nitial 'val%ation

J F M A M J J A S O N Da S%bective :indings

b @bective :indings

c Short Term Aoals

d =ong Term Aoals

e Prior level of f%nctioning

f Patient-:amily $nvolvement

11 Progress otes>

a Completed daily inpatient6b Complete every to eeks o%tpatient6

c $ndicated treatment rendered

d :re7%ency of treatment

e =ocation

f /ny change in condition noted

g Patient-family %nderstanding of therapy

111 ischarge of S%mmary incl%des>

a Aoals met

b :%nctional stat%s %pon discharge

c ?ome Program

d ,echanism for :ollo)%p


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P%ysiot%erapy-0n!ironmental ounds

a Treatment /rea1 Treament area enclosed to g%arantee privacy to patient

2 o modality e7%ipment in c%bicle other than e7%ipment to be %sed

3 Clean linen for each patient

b 'lectrical Safety

1 se only e7%ipment ith three ire line cordsJ old e7%ipment

properly gro%nded"

2 /ll electrical connection tight

,an%al-a%to ad%stments in orking order

3 'lectrical e7%ipment inspected every # months

c


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4 Sterili8ed 7 month

5 Covered at all times

P%ysiot%erapy-0n!ironmental ounds

f ltraso%nd

1 nit gro%nded

2 /ll sitches off

3 Transd%cer and pl%g connections tight and clean

g 'lectrical Stim%lator

1 /ll ire and pl%g connections tight

2 Controls off before and after %se

3 'lectrodes in good condition

h Transc%taneo%s 'lectrical erve Stim%lator

1 =ine Cord nits sho%ld be gro%nded

2 /ll electrodes ashed and alloed to dry

3 ;atteries recharged"

i $ntermittent Traction

1 nit gro%nded

2 ials at 8ero

3 ?ead halters. straps. cables. halter fastenings sec%re

'7%ipment ,aintenance

1 9eg%lar periodic e7%ipment checks performed ith doc%mentation


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Performance Measures-Food Ser!ices(*

1 %tritional Care

a 'val%ation of 7%ality and appropraiteness of n%tritional caregiven to patients on t%be feeding"

J F M A M J J A S O N D

1

1


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Performance Measures-Food Ser!ices(.

d 'val%ation of appropriatness of diet order to iagnosis

1 id diet provide ade7%ate calories to meet the 9/D

2


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Performance Measures - P%armacy

1 Preparation and ispensing

a ispensing 'rrors1


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Medication 1se

1 Prescribing and @rdering

a /ntibiotic 9evie

1 /ppropriateness

2 Prophylactic %se

a6 $nitial dose not later than 1 ho%r prior to s%rgery

b6 :inal dose not less than 4( ho%rs after s%rgery

3 'mpiric se

4 se of restricted dr%gs

5 $nitiation of antibiotic 24 ho%rs post part%m

b /ppropriate %se and management of dr%gs

1 Thrombolytic agents

2 TP

3 Pitocin

4 'mergency epartment

c Prescribing Patterns

2 'ffects on Patients

a /dverse dr%g reactions


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Performance Measures - 2nfection /ontrol J F M A M J J A S O N

1 S%rveillance. Prevention and Control of $nfection

a /vailability of protective barrier as per standard preca%tions re7%irement"b $nfectio%s aste handling and disposal

c osocomial $nfections>

1 Patients on ventilator ho developed pne%monia

2 Post)operative pne%monia in patients e+periencing>

i6 Cholecystectomy

ii6 Splenectomy

iii6 /bdominal ;ypass graft

iv6 /bdominal perineal resection

v6 Colon resection

3 Primary bloodsream infection in patients ith>i6 Central line

ii6 mbilical line

4 evelopment of o%nd infections in GCleanG cases

11 'd%cation

Pengu)uran 3iner4a - Pengendalian 2nfe)si

1 S%rveillance. Pencegahan dan Pengendalian $nfeksi

a Ketersediaan penghalang pelind%ng ses%ai keb%t%han tindakan pencegahan standar"

b Penanganan limbah infeksi%s dan pemb%angan

c $nfeksi osokomial>

1 Pasien pada ventilator yang mengembangkan pne%monia

2 pne%monia pasca operasi pada pasien yang mengalami>

i6 Kolesistektomi

ii6 Splenektomi

iii6 per%t ;ypass graft

iv6 per%t reseksi perineal

v6 Colon reseksi

3 $nfeksi bloodsream primer pada pasien dengan>

i6 Central line


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ii6 line %mbilical

4 Pengembangan infeksi l%ka dalam kas%s GCleanG

a /ll clinical staff ill have inservice in infection control-standard preca%tion"

Sem%a staf klinis akan memiliki intern dalam pengendalian infeksi - tindakan pencegahan standar"

5uarterly 0!aluation of Standard Precautions$Body Su'stance 2solation

ate>

,ethodology> Conc%rrent st%dy of ?ealthcare / total of observations made in the department

9evieer>

Yes No Non-compliant

1 Aloves orn hen draing blood

2 Aloves orn hen handling blood and body fl%ids

3 Aloves changed bteen patientsD

4 ?ands ashed after gloves removedD

5 ,asks. goggles. gons readily availableD

# oes employee kno location of '7%ipmentD


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& ,asks. goggles orn if splattering possibleD

( sed needles not recapped and disposed of in proper containers

* /reas properly cleaned folloing contamination ith body fl%idD

'val%asi Tri%lan Standar ;ahan Keaspadaan - T%b%h $solasi

Tanggal >

,etodologi> St%di Conc%rrent Pekera Kesehatan

Tem%an> Sebanyak pengamatan yang dilak%kan di departemen

resensi b%k%>

1 Sar%ng tangan dipakai saat menggambar darah

2 Sar%ng tangan dipakai saat menangani darah dan cairan t%b%h

3 Sar%ng tangan ber%bah bteen pasienD

4 Tangan dic%ci setelah sar%ng tangan dilepasD

5 ,asker. kacamata. ga%n tersediaD

# /pakah karyaan mengetah%i lokasi '7%ipmentD

& ,asker. kacamata yang dikenakan ika m%ncrat m%ngkinD

( Bar%m bekas tidak recapped dan dib%ang dalam adah yang tepat

* /rea benar dibersihkan kontaminasi berik%t dengan cairan t%b%hD

Aoogle Teremahan %nt%k ;isnis>Perangkat PeneremahPeneremah Sit%s


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Performance Measures - Business Office

1 @rganisation Performance $mprovement


a C%stomer Complaints !F

b 'rrors in Patient ;ills !F

c 'rror in $ns%rance-Corporate claims !F

d T%rn aro%nd time for patient discharge to billing over 3! days !F

Performance Measures - Materials Management

2 @rganisation Performance $mprovement

a S%pplies are available for filling departmental orders

b %mber of vendors for similar s%pplies are minimi8e for cost controlc Special s%pply re7%est are filled ithin time frame re7%ested

d @ld-o%tdated s%pplies in Store


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is)s Management Mont%ly Safety /ommittee eport


1 a Patient $n%ry

b 'mployee $n%ry

c 0isitor $n%ry

d eedle Stick $n%ry

e Sec%rity 'lopement

f :al l /ttended

g '7%ipment :ail%re or ,alf%nction

h '7%ipment ser or ,alf%nction

i '7%ipment ser 'rror

tility :ail%re or ,alf%nction

k tility ser 'rror

l ,edical evice 9ecalls

o of /dmissions

/verage aily Cens%s

o of ischarges

Cedera pasien

Cedera karyaan

Cedera peng%n%ng

eedle Tongkat Cederakeamanan 'lopement

at%h ,enghadiri

Kegagalan peralatan ata% Ker%sakan

Peralatan Pengg%na ata% Ker%sakan

Kesalahan Peralatan Pengg%na

Kegagalan %tilitas ata% Ker%sakan

Kesalahan %tilitas Pengg%na

/lat Kesehatan Penarikan

idak ada Penerimaan

9ata)rata ?arian Sens%s

Tidak ada dari Pemb%angan


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11 'nvironment of Care

a $ncidents of needlestick $n%ry shall decrease by F

7%arterly

b 'mployee back in%ries shall decreasse by F 7%arterly

c /ll employees are inserviced ann%ally on>

16 :ire Safety

26 ?a8ardo%s ,aterials

36 ?a8ard detection S%rvey

46 $llness and $n%ry Protection Program

56 '+pos%re Control Program

#6 'mergency Preparedness Program&6 Sec%rity Program

nsiden Cedera ar%m akan men%r%nF

tri%lanan

Cedera p%ngg%ng Karyaan har%s decreasse olehF tri%lanan

Sem%a karyaan inserviced setiap tah%nnya pada>

16 :ire Safety

26 ;ahan ;erbahaya36 deteksi bahaya S%rvey

46 Penyakit dan Program Perlind%ngan Cedera

56 Program Pengendalian 'kspos%r

#6 Program Kesiapsiagaan ar%rat

&6 Program Keamanan

Performance Measures - 0ngineering Department Benc%mar)s of *++,


a Patient-'mployee Safety


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F M A M J J A S O N D

16 isaster rills

26 :ire rills

36 'mergency Aenerator Proced%re

46 Policies-Proced%res c%rrent

56 Preventive ,aintenance Proced%res ithin 3! days c%rrent6

#6 epartment $nservice monthly

&6 :ire Sprinkler 0alves open e+cept d%ring service6

(6 ;io)med e7%ipment Checksc%rrent to month d%e date6

*6 9o%nd Checks perform ,onday to :riday6

1!6


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a Satisfaction E%estionnaire

b Patients Complaints

c Staff Complaints


a /ll environmental service staff ill complete ann%al $nservice)

on $nfection Control and Safety"

b ?o%sekeeping $nspections


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Organi6ational Performance 2mpro!ement Board eport

Performance Measures Benc%mar)s /omments 57 * 57 . 57 8

1 0ol%mea %mber of $npatient discharges

1 Total n%mber if discharges

/verage length of stay @=@S6

2 Total n%mber of Corporate discharges


3 Total n%mber of $ns%rance discharges


b o day-o%tpatient s%rgeries

c o of 'mergency visits

d F @cc%pancy

11 ,ortality

a Total n%mber of deaths

1 F of deaths

b Perioperative mortality rate deaths ithin 4( ho%rs

of s%rgery or invasive proced%re6

c eborn ,ortality 9ate

d ,aternal ,ortality 9ate

e o of patient deaths in 'mergency epartment

f F of deaths meeting criteria or e+pected %stifiedmortality"

g %mber of a%topsies performed"

111 ?ospital /c7%ired $nfection

a Total 9ate

b Clean s%rgical rate

c Post part%m infection rate

d eonatal $nfection 9ate


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10 9isk ,anagement

a o of claims involving patient in%ry-death

b o of claims involving hospital risk-loss

c o of ,edication 'rrors

d o of patient-visitor falls

0 Case ,anagement

a enial rate for private ins%red patients

b /ppeal s%ccess rate

c enial rate for Corporate patients

d /ppeal s%ccess rate

01 ,edication se

a o of dr%g reactions res%lting in prolonged

length of stay"

b o of dr%g reactions res%lting in temporary or

permanent patient in%ry and potential hospital

liability"

c o of cases revieed not meeting established

criteria"

011 ;lood sage

a o of transf%sion reactions res%lting in prolonged

length of stay"

b F of cases revieed not meeting established criteria

c Crossmatch-transf%sion ratio

d o of asted %nits

0111 S%rgery-$nvassive Proced%res

a nplanned ret%rns for s%rgery

b o of Complications

c o of tiss%e cases revieed

d o of meeting criteria

e o of non)tiss%e cases

f o of meeting criteria


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1I Cesarean Sections

a F of meeting criteria

b F of repeat proced%res

c F of primary proced%res

d F of 0aginal deliveries secondary to C)section

deliveries 0;/C6

I Codes

a F of s%ccessf%l codes performed in>

1 'mergency epartment

2 SC

3 ,edical-S%rgical

4 Pediatrics

5 @;

I1 Transfer to another ac%te care facility

a o of emergency patients transferredb o of inpatients transferred for services not

provided by the hospital

c F of transfers meeting transfer criteria"

I11 Special Care nit

a o of transfer from loer level of care in hospital to special

care %nit"

b o of patients admitted to special care %nits not

meeting admission or discharge criteria"

c o of patients ret%rned to special care %nit ithin4( ho%rs of discharge from %nit"

d o of patients that die ithin 4( ho%rs of discharge

from %nit"

I111 9eadmissions

a o of readmissions ithin 3! days from related or

similar diagnosis-treatment"

b F of cases meeting criteria for appropriateness

of first discharge and of readmission


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I10 /,/s

a o of 'mergency patients leaving /,/

b o of other patients leaving /,/

I0 Patient Complaintsa o of patient-family complaints involving patient

care

b o of patient-family complaints involving billing errors

or charges for services

c o of patient-family complaints involving a hospital

provided service or employee

d F of %nresolved complaints


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Performance Measures - 0mergency Department

1 /ssessment

a Aeneral oc%mentation-Triange 1!!F

11 Care of the Patient

a Standard of Care> 1!!F

1 ?ead $n%ry

2 Poisoning-@verdose

3 /bdominal pain)non)tra%matic

4 Shortness of breath

5 :ract%res-islocations-Sprains

# 'ye Complaints

& Tra%ma

( 0aginal ;leeding

* =aceration1! Sei8%re

11 Chest pain

12 Pediatrics

13 Pediatric :ever

b ,edication se !F

1 ,edication 'rror

111 Contin%%m of Care

a $nfection Control of nitb Standard Preca%tion

10 @rgani8ational Performance $mprovements

a Patient-physician complaints

b /,/

c =


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b @rientation to nit

c ,edication taken at home

d /llergies

e Special eeds

System 9evie)both s%bective and obective

a Aastrointestinal

b Cardiovasc%lar

c 9espiratory

d e%rological-'ndocrine

e ,%sc%loskeletal

f ,ental Stat%s

g ischarge Planning

2 Plan of Care

a Plan implemented on date of admission

b Plan individ%ali8ed on date of admission

c 'ach problem n%rsing diagnosis6 has o%tcome ith deadline

d Plan is %pdated timely evidenced by>

1 iscontin%ance of problems solved

2 e problems initiated ith date

3 @%tcome

e Charting on %rses notes are directly related to problems in

plan of care at least once in 24 ho%rs"

Nursing Performance Assessment (.

3 ,edication

a /re the reasons for P9 medications recordedDb ?as the effect of P9 medication been chartedD

c ,eds are charted ith the appropriate time. ro%te dose and site of inection

d ,/9 contains initials. f%ll signat%res. and title of administering n%rse"

e /re GomittedG or Gref%sedG medications charted properly on the medication

record and in the n%rses notesD

4 $ntake-@%tp%t

a $ntake-@%tp%t ere recorded each shift

b Totaled each 24 ho%rs"


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b Totaled each 24 ho%rs"

5 oc%mentation of $0 Care

a 9eflects site checked each shift

b Signs of infiltration-phlebitits doc%mented ith follo)%pc Site-si8e and type of needle %sed to start $0 Chart

d $0 T%bing related

e $0 ressing site is dated. timed and initialed"

# Patient 'd%cation

a Patient ed%cation d%ring hospitali8ation is apparent

b Patient ed%cation is specific to care plan problems

& Transfer

a Transfer note completed by transferring %nit

b /dmission transfer note completed by admitting %nit"

Nursing Performance Assessment(8

( =egibility-=egality

a $s n%rsing record legibleD

b /re orders noted ith>

1 Time

2 ate

3 Signat%re of rsponsible 9

c )

1 'ach n%rsing notation

2 'nds each n%rsing page

e


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1!

1 ated2 Changed every &2 ho%rs reg%lar $06

3 Changed every 24 ho%rs hyperal6

c Site is clean and itho%t evidence of infiltration"

14 @ral ?ygeine of $ncapacitated Patients

a There is evidence of daily cleaning of teeth-dent%res

b $s patient on high dose and-or m%ltiple antibioticsD

c $f so. evidence of thr%shD

d octor notified of possible f%ngal infectionD


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e =ips and tong%e cleaned and most%rised

f ent%res are stored in containers labeled ith patients name and room n%mber

Nursing Performance Assessment (:

15 :oley Catheter Care

a :oleys catheter sec%red to patients thigh

b $s the catheter t%bing straight and free of kinks or coiling

c $s the straight drainage bag>

1 off the floor

2 Clean-free of odor

3 Placed at the right side of the bed patient is facing hen t%rned

4 ;elo the level of the patient bladder

d $s the catheter in good condition. free of tape or m%so%s b%ild%p

e $s %rine floing ell thro%gh the t%bingD onard directionD

f $s reason for the :oleys catheter doc%mentedD

1# Patient 'd%cation

a Can patient verbali8e %nderstanding of>

1 Pending proced%resD

2 eeded specimen collectionD

3 isease processD4 %rsing Care being deliveredD

5 ischarge-needs planningD

# oes patient verbali8e %nderstanding of pre)operative careD

& oes patient verbali8e %nderstanding of @T and recovery room careD

a6 /nesthesia

b6 :re7%ent vital signs

( oes patient verbali8e %nerstanding of post)operative careD

a6 T%rn. co%gh. deep breathD

b6 T%bes-e7%ipment to e+pectD

c6 P@ stat%s and diet advancementDd6 /vailability of pain medicationD

e6 $mportance of e+pressing feelingsD


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Performance Measures- /ritical /are 1nit


a /vailability of Physician

J F M A

1 e Cardiac patients seen ithin 4 ho%rs

2 /ll other ne admits seen ithin # ho%rs

3 Physician responds to 'mergency call ithin 3! min%tes

b 9et%rn to the Special Care nit ithin 4( ho%rs of transfer to a

loer level of care

11 Care of the Patient

a Standards of Care

1 Press%re ,onitoring

2 0entilator Patient Care

3 Temporary Pacer4 ,$-9@ ,$

5 C@P

# C?:

& Shock

( Pain ,anagement

* Thrombolytic Therapy

1! Skin $ntegrity

11 ?emodialysis

b $0 Therapy

c :oleys Catheter Care

d @ral ?ygeine of $ncapacitated patients

e ,edication se> medication errors

d , di ti C t


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d ,edication Carts

01 $nformation ,anagement

a oc%mentation

1 /ssessment

2 Plan of Care

3 ,edication

4 $ntake-@%tp%t

5 oc%mentation of $0 Care

# Patient 'd%cation

& Transfer( =egibility-=egality


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M J J A S O N D


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Operating oom-2nfection /ontrol /riteria


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Operating oom 2nfection /ontrol /riteria

1 $ndicator> $ntegrity of sterile field is maintained" ,et ot ,et

a S%rgical hand scr%b performed according to policy and proced%re"

b Proper goning and gloving techni7%e %sed"

c Sterile drapes placed on all tables %sed for e7%ipment and intr%ments"d Tables are clean and dry prior to %se

e $n draping. material held compact and above aist level and draping

done from operative site to periphery"

f /ll instr%ment trays shall be assembled. packaged. sterili8ed and stored according to standards

a Stored in proper area

b $tem is properly labelled"

c =ebel is legible

d Contains the folloing>

'+piration dates if applicable6


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Maintenance of Blood$Fluid Precautions in O7

$ndicator> Standard Preca%tions observed and maintaineda Aloves are orn hnever contact ith blood and body fl%ids is anticipated"

b Aloves are orn hen moving patients postoperatively

c Aloves are orn hen to%ching m%co%s membranes or open skin

d ?ands are ashed beteen patient contacts

e ?ands are ashed after accidental contact ith blood-body fl%ids and-or

after gloves are removed"

f ,asks and protective eye ear provided-orn henever aerosoli8ation

or splattering or blood-body fl%ids is anticipated e+t%bation. laryngoscopy etc6

g ,asks and protective eye ear provided-orn for all scr%bbed personnelh Sharp obects needles-blades6 are handled in s%ch a manner as to prevent

accidental c%ts-p%nct%res

i ;lood spills are cleaned immediately ith appropriate disinfectant"

/ll re%sable items are appropriately sterili8ed"

k sed needles are not broken-recapped. b%t are discarded in p%nct%re

resistant containers"

l se of appropriately labelled infectio%s aste-linen containers"

Patient 0;periences no 7issue Damage or /ompromised /irculation Pre)operative assessment and doc%mentation of patients physical stat%s is completed"

a Condition of skin notedb '+istence of abnormalities. in%ries. sensory impairment noted-doc%mented"

c Previo%s s%rgery"e+istence of metal implants noted-doc%mented

d Cast inspected for ade7%ate padding-protection

e /ppropriate-ade7%ate padding-positioning aids %sed

f Patient offered arm blanket. repositioned etc

g ?ypothermia %nit %sed according to man%fact%rers recommendations"

Psyc%ological Aspects of /are to Patients in t%e O7

$ndicator> E%ality and appropriateness of Psychological s%pport to patients in the @T

a /ssessment of Psychological aspectsb Patient enco%raged to ventilate concerns and fears

c E%estions ansered regarding n%rsing matters

d E%estions on ,edical Care referred to Physician

e 9oom preparations completed prior to patient entry

f oise-traffic minimi8e

g Patient orientated to operating room as needed

h Clear and concise e+planations given

i Patients emotional stat%s comm%nicated to other appropriate team members

Patient remained ith d%ring ind%ction

e $f t%rned. done on signal by anesthesiologist


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g y g

f ?ead t%rned gently and s%pported

Patient is free from 2n4ury elated to Positioning(contd

$ndicator> /ppropriateness of positioning of patients in @T

g 'ars and eyes protectedh Press%re prevented on chest incl%ding d%ring proced%re

i /rms placed on armboards. pronate palms. press%re on elbos prevented"

Safety strap in place

k Press%re points checked-padded

l o redness. br%ises. evidence of in%ry or press%re areass noted on -C form @T

m o problems ith circ%lation d%e to positioning noted

n Position-change in position doc%mented

Patient is free from in4ury elated to transfer from t%e O7 ta'le to t%e stretc%er

$ndicator> /de7%acy of lifting and moving patients in @T

a /de7%ate personnel are sec%red for help

b /ll body parts are s%pported d%ring move

c Patient moved ith %nison ith directions

d Proper body mechanics %sed by all personnel

e Consideration given to the patients condition

f Patient is made comfortable folloing move

g Safety strap-side rails etc. %tili8e

h There is no complaint from the patient regarding move

i There is no in%ry-complaint of the personnel

$0 and all other e7%ipment protected d%ring movek $0 and all e7%ipment remain intact folloing the move"

Maintenance of Fluid$0lectrolyte Balance

$ndicator> :l%id-'lectrolyte balance ill be maintained

a $ntake monitored and doc%mented

b @%tp%t monitored and doc%mented

c 'vidence of post)operative bleeding monitored-doc%mented

d Pre)operative res%lts checked

e /bnormal laboratory val%es comm%nicated to appropriate team members

f ;lood available as orderedg ;lood replacement initiated as ordered

h Post)operative na%sea-emesis noted-doc%mented

Patient is free from 2nury elated to 0lectrical #a6ards

$ndicator> The 'lectro)s%rgical nit 'S6 shall be %sed folloing all safety g%idelines in the @T

a 'S inspected by bio)medical ithin si+ months

b 'S clean and protected from spills

c 'S not %sed in presence of flammable agents

d Pl%g. cord and connections inspected before %se

e Cord reaches o%tlet itho%t stress

7 oc%mentation incl%des>Aenerator $ n%mber. Aro%nd pad placement-location.


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'KA pads placement-location. Patients skin condition before and after %se"

7rending S%eet

3ey Function$Performance Measures Benc%mar)


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y

1 Management of 2nformation

a" oc%mentation J F M A M J J A S O N D

1 Pre)op checklist complete and 9 signat%re 1!!F2 =aboratory-'KA res%lts on chart 1!!F

3 ? P on chart 1!!F

4 $f no ? P. evidence of ?-P dictated 1!!F

5 Consent for proced%re completed and signed 1!!F

# $f ?ysterectomy. special ?ysterectomy consent on chart" 1!!F

& Sterili8ation permit on chart if applicable 1!!F

( $nformed consent doc%mented on progress notes 1!!F

* $ndications for s%rgery doc%mented by physicians in 1!!F

charge in progess notes if patient is %nable to sign

and there is no g%ardian"

1! $ band on patient 1!!F

11 $nformed consent for blood if indicated 1!!F

12 $nformed consent for ;reast Cancer treatment if indicated6 1!!F

11 Sur!eillance= Pre!ention and /ontrol of 2nfections

1 $ntegrity of sterile field is maintained 1!!F

2 /ll instr%ment trays shall be assembled. packed.

sterili8ed and stored according to standard" 1!!F

3 Standard preca%tions observed-maintained in @T 1!!F

111 Assessment

1 Pre)operative assessment and doc%mentation of

patients physical stat%s is completed" 1!!F10 /are of Patient

1 E%ality and appropriateness of psychological s%pport

to patients in the operating room" 1!!F

2 /ppropriateness of positioning of patients in @T 1!!F

3 /de7%acy of lifting and moving patients in @T 1!!F

4 :l%id and electrolyte balance is maintained" 1!!F

0 Management of t%e 0n!ironment of /are

1 'S 'lectrical S%rgical nit6 shall be %sed folloing

all safety g%idelines in @T

01 Organisational Performance 2mpro!ement1 $ntraoperative readiness of @perating room staff 1!!F

copy of performance measure kebidanan

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