EP18EO

 

Culture of Safety EP18EO

 

• Provide eight of the most recent, consecutive quarters of unit- or clinic-level nurse-sensitive, clinical indicator data to demonstrate outperformance of the mean, median, or other measure of central tendency (benchmark provided by the vendor’s national database). Data must be the most recent eight, complete quarters available from the vendor(s). Select and report data for all applicable inpatient care units.
  
  The required patient indicators for all inpatient care organizations include falls with injury, hospital-acquired pressure injuries (HAPI) stage 2 and above, and two others from the list.
  
  

• Falls with injury
• Hospital-acquired pressure injury (HAPI) stages 2 and above

 

Select two others:

• Central line-associated bloodstream infection (CLABSI)
• Catheter-associated urinary tract infection (CAUTI)
• Clostridium difficile (C-Diff)
• Methicillin-resistant Staphylococcus Aureus (MRSA)
• Venous Thromboembolism (VTE)
• Peripheral Intravenous Infiltrations (PIV)
• Physical and sexual assaults
• Device-related hospital-acquired pressure injury (HAPI)
  
  

RECOMMENDATION:  If available, use vendor-provided graphs for nurse satisfaction.  Graphs must meet Magnet specifications.

 

 

Data Presentation Requirements:

• Display each unit or clinic using guidance provided on page 53 of the 2019 ANCC Magnet® Application Manual.
• You must provide the most recent full eight quarters of data for all four indicators.

 

Level of Data

• Unit-or clinic-level data. If data are not available at the unit or clinic level, present at the next aggregated level if available from the vendor (e.g. clinic groups).
• Explain units or clinics within aggregated data.
• Explain any units not included.

 

Benchmark statistic.

• Use of mean, median or other measure of central tendency provided by the vendor’s national database benchmark.

 

Comparison Group or Cohort

• Use of an appropriate comparison group may change between units or clinics.
• Comparison group label must be depicted on table and graph.

 

Graph presentation/

• Single unit or clinic presentation.
• A different mean or median may be used for each graph.
• Up to four units or clinics may be presented on one graph.
• If the two or more units are displayed on one graph, all units must have the same comparison benchmark and cohort.

 

 

Example a: Falls with Injury

Greenwich Hospital participates in the Press Ganey National Database of Nursing Quality Indicators (NDNQI) for nurse sensitive indicators. Data are presented at the unit level for the most recent eight quarters of data available from the vendor, 1Q2018-4Q2019.

 

(Evidence EP18EOa-1, Falls with Injury, Inpatient)

 

 

Example b: Hospital-Acquired Pressure Injury, Stages 2 and Above

Greenwich Hospital participates in the Press Ganey National Database of Nursing Quality Indicators (NDNQI) for nurse sensitive indicators. Data are presented at the unit level for the most recent eight quarters of data available from the vendor, 1Q2018-4Q2019.

(Evidence EP18EOb, HAPI, Stages 2 and Above, Inpatient)

 

 

Example c: Central Line-associated Blood Stream Infection (CLBSI)

Greenwich Hospital participates in the Press Ganey National Database of Nursing Quality Indicators (NDNQI) for nurse sensitive indicators. Data are presented at the unit level for the most recent eight quarters of data available from the vendor, 1Q2018-4Q2019.

 

(Evidence EP18EOc-1, CLABSI, Inpatient)

 

 

Example d: Catheter-associated Urinary Tract Infection (CAUTI)

Greenwich Hospital participates in the Press Ganey National Database of Nursing Quality Indicators (NDNQI) for nurse sensitive indicators. Data are presented at the unit level for the most recent eight quarters of data available from the vendor, 1Q2018-4Q2019.

 

(Evidence EP18EOd-1, CAUTI, Inpatient)