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Highland Hospital curtails patient harm

Patient harm is a major burden on healthcare providers. Early detection and focused prevention efforts can reduce incidents, improving patient experience and decreasing morbidity and mortality, as well as limiting risk to the provider. In 2018, Highland Hospital (a member of UR Medicine) implemented a five-year strategic plan to reduce preventable harm at the facility by 20%.

With leadership support and buy-in from frontline staff, Highland Hospital implemented best practices related to the reduction of hospital-acquired conditions, including surgical site infections. The project targeted the reduction of bioburden on surgical instruments to less than 2%. To achieve this, they established standardized processes and procedures in the first step of the decontamination process (point of use cleaning). Moreover, the project created a quality assurance process to ensure project sustainability. The project team used Lean Six Sigma methodology and tools along with a project management framework to achieve these outcomes.

Today, the number of bioburden incidents is now consistently under 1%. The hospital succeeded at increasing point-of-use cleaning compliance and decreasing the number of unacceptably soiled instruments being sent to the sterile processing department. When the audits started in July 2018, compliance was roughly 80%. Compliance has increased month over month with a projected sustainable compliance rate of 95% or higher. Additionally, the number of instruments having to be returned to the decontamination area from the assembly area is at an all-time low.

For more information, contact Caitlin M. Smith MS, RN, CNOR, CSSM, NE-BC, director, perioperative nursing, at (585) 341-6569 or caitlin_smith@urmc.rochester.edu.