table of contents - regina qu'appelle health region · cupar and district nursing home . 2...

1

TABLE OF CONTENTS

FINAL REPORT – CORPORATE AUDITS

TABLE 1 - SUMMARY

TABLE 2

FIGURE 1

FINAL REPORT – SELF AUDITS

TABLE 3 - SUMMARY

TABLE 4

FIGURE 2

FINAL REPORT – PATIENT CARE AUDITS

TABLE 5 - SUMMARY

FIGURE 3

FIGURE 4

FIGURE 5

FIGURE 6

FIGURE 7

FIGURE 8

FIGURE 9

ALL NATIONS HEALING HOSPITAL

BALCARRES INTEGRATED CARE CENTRE

BROADVIEW CENTENNIAL LODGE

BROADVIEW UNION HOSPITAL

CENTRAL PRIMARY HEALTH CARE NETWORK

CUPAR AND DISTRICT NURSING HOME

2

ECHO LODGE

ELMVIEW EXTENDICARE

GOLDEN PRAIRIE HOME

GRENFELL HEALTH CENTRE

GRENFELL PIONEER HOME

INDIAN HEAD UNION HOSPITAL

KIDNEY HEALTH CENTRE

LONG LAKE VALLEY INTEGRATED CENTRE

LUMSDEN HERITAGE HOME

MENTAL HEALTH AND ADDICTIONS TREATMENT CENTRE

MENTAL HEALTH CLINIC 2110 HAMILTON 3RD FLOOR

MONTMARTRE HEALTH CENTRE

NATIVE HEALTH SERVICES

PARKSIDE EXTENDICARE

PASQUA HOSPITAL – 3A

PASQUA HOSPITAL – 3B

PASQUA HOSPITAL – 3C

PASQUA HOSPITAL – 3D






PASQUA HOSPITAL – C.T.

PASQUA HOSPITAL – CARDIO/NEURO DIAGNOSTICS

3

PASQUA HOSPITAL – DAY SURGERY

PASQUA HOSPITAL - EMERGENCY

PASQUA HOSPITAL – EYE CENTRE

PASQUA HOSPITAL - ICU

PASQUA HOSPITAL – LABORATORY & PHLEBOTOMY

PASQUA HOSPITAL - MAMMOGRAPHY

PASQUA HOSPITAL - MSU

PASQUA HOSPITAL – NUCLEAR MEDICINE

PASQUA HOSPITAL - OR

PASQUA HOSPITAL - PACU

PASQUA HOSPITAL – RESPIRATORY THERAPY

PASQUA HOSPITAL – SHORT STAY

PASQUA HOSPITAL – THERAPY SERVICES

PASQUA HOSPITAL - ULTRASOUND

PASQUA HOSPITAL – X-RAY

QU’APPELLE HOUSE

REGINA CENTRE CROSSING - FMU

REGINA CENTRE CROSSING – SURGICAL ASSESSMENT CENTRE

REGINA LUTHERAN HOME

REGINA GENERAL HOSPITAL – 0D/1D

REGINA GENERAL HOSPITAL – 3E

REGINA GENERAL HOSPITAL – 4B

REGINA GENERAL HOSPITAL – 4F

REGINA GENERAL HOSPITAL – 5A


4




REGINA GENERAL HOSPITAL - ANGIO

REGINA GENERAL HOSPITAL – C.T.

REGINA GENERAL HOSPITAL – CARDIO/NEURO DIAGNOSTICS

REGINA GENERAL HOSPITAL – CATH LAB

REGINA GENERAL HOSPITAL - CCU

REGINA GENERAL HOSPITAL - CSU

REGINA GENERAL HOSPITAL – DAY SURGERY

REGINA GENERAL HOSPITAL - EMERGENCY

REGINA GENERAL HOSPITAL - ENDOSCOPY

REGINA GENERAL HOSPITAL – LABORATORY & PHLEBOTOMY

REGINA GENERAL HOSPITAL – LABOUR & BIRTH

REGINA GENERAL HOSPITAL - MDRU

REGINA GENERAL HOSPITAL - MICU

REGINA GENERAL HOSPITAL - MRI

REGINA GENERAL HOSPITAL - NICU

REGINA GENERAL HOSPITAL – NUCLEAR MEDICINE

REGINA GENERAL HOSPITAL - OR

REGINA GENERAL HOSPITAL - PACU

REGINA GENERAL HOSPITAL – PEDIATRIC OUTPATIENT

REGINA GENERAL HOSPITAL – PULMONARY FUNCTION

REGINA GENERAL HOSPITAL - RENAL

REGINA GENERAL HOSPITAL – RESPIRATORY THERAPY

5

REGINA GENERAL HOSPITAL – SHORT STAY UNIT

REGINA GENERAL HOSPITAL - SICU

REGINA GENERAL HOSPITAL - THERAPIES

REGINA GENERAL HOSPITAL - ULTRASOUND

REGINA GENERAL HOSPITAL – WOMEN’S HEALTH

REGINA GENERAL HOSPITAL – X-RAY

REGINA PIONEER VILLAGE – 2 EAST

REGINA PIONEER VILLAGE – 2 WEST




REGINA PIONEER VILLAGE – HOSTEL

REGINA PIONEER VILLAGE – MAIN WEST

SANTA MARIA

SILVER HEIGHTS SPECIAL CARE HOME

SOUTHEAST INTEGRATED CARE CENTRE – ACUTE CARE

SOUTHEAST INTEGRATED CARE CENTRE - LTC

SOUTHEAST INTEGRATED CARE CENTRE - DIAGNOSTICS

ST. JOSEPH’S INTEGRATED CARE CENTRE

SUNSET EXTENDICARE

WASCANA REHABILITATION CENTRE – 2-5





6


WASCANA REHABILITATION CENTRE – ADULT THERAPIES

WASCANA REHABILITATION CENTRE – CHILDREN’S PROGRAM

WASCANA REHABILITATION CENTRE - FRP

WASCANA REHABILITATION CENTRE – MAIN 5


WASCANA REHABILITATION CENTRE – ORTHOTICS & PROSTHETICS

WASCANA REHABILITATION CENTRE - RENAL

WASCANA REHABILITATION CENTRE – RESP (2-6)

WHITEWOOD COMMUNITY HEALTH CENTRE

WILLIAM BOOTH SPECIAL CARE HOME

WOLSELEY MEMORIAL INTEGRATED CARE CENTRE

7

FINAL REPORT – CORPORATE AUDITS

For October – December 2017, a total of 547 hand hygiene observations were submitted for analysis.

For the analysis of corporate audits, the following definition of hand hygiene was used:

Compliant:

1) Person was not observed with artificial nails/nail polish or jewellery not approved

Non-compliant:

1) Person was observed with artificial nails/nail polish not allowed, and/or

2) Person was observed with jewellery not allowed

8

Table 1: Regional hand hygiene compliance rates, Corporate Areas, September – December 2017

Measurement September 2017 October 2017 November 2017 December 2017

Number of observations submitted 195 178 144 225

Compliance at the region level 94% 94% 97% 91%

Noncompliance at the region level 6% 6% 3% 9%

Percentage of observations in which the

healthcare worker wore jewellery 5% 6% 2% 8%


healthcare worker had artificial nails/nail

polish

3% 1% 1% 2%

9

Table 2: Results for facilities, services, and units that conducted Corporate Audits, October –

December 2017

Corporate Area Overall hand hygiene

compliance

Percentage of

observations in which

the healthcare worker

wore jewellery

Percentage of



had artificial nails/nail

polish

Academic Health Sciences

69% 31% 0%

Clinical Engineering

91% 9% 9%

Employee Health & Safety

100% 0% 0%

Enterostomal Therapy

96% 4% 0%

Environmental Public Health

96% 4% 0%

Facilities Management – RGH

100% 0% 0%

Governance and Policy

100% 0% 0%

Grenfell Regional Office

92% 8% 0%

Home TPN 100% 0% 0%

IT – Infrastructure 93% 7% 0%

IT – Point of Care 93% 7% 0%

IT -Corporate and Clinical Support

94% 2% 4%

Learning and Development

100% 0% 0%

10

Corporate Area Overall hand hygiene

compliance

Percentage of



wore jewellery

Percentage of



had artificial nails/nail

polish

Patient Safety and Risk Management

100% 0% 0%

PH- Medical Media 100% 0% 0%

PPHS 2110 Hamilton Admin

100% 0% 0%

Primary Health Care – Navigation Services

80% 20% 0%

Public Health Admin – 2110 Hamilton

100% 0% 0%

Quality and Strategy 2180 Victoria Ave

100% 0% 0%

Quality and Strategy Primary Health

100% 0% 0%

Research and Health Information

83% 13% 3%

RGH – HIMS 90% 10% 7%

Security and Parking Services

100% 0% 0%

Workforce Planning and Development

100% 0% 0%

WRC – Communications

100% 0% 0%

WRC – Executive Offices

100% 0% 0%

Overall 94% 6% 1%

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Figure 1: Hand hygiene compliance rates, Corporate Areas, September – December 2017

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FINAL REPORT – SELF AUDITS

For October – December 2017, a total of 2912 hand hygiene observations were submitted for

analysis.

For the analysis of self-audits, the following definition of hand hygiene was used:

Complaint:

1) Hand gel or soap/water

Non-compliant:

1) Gloves only,

2) Missed hand hygiene opportunity,

3) Jewellery, and/or

4) Artificial nails/nail polish

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Table 3: Regional hand hygiene compliance rates, Self-Audits, September – December 2017

Measurement September 2017 October 2017 November 2017 December 2017




Percentage of observations in which

the healthcare worker wore jewellery 1% 1% 1% 2%


the healthcare worker had artificial

nails/nail polish

1% 1% 1% 1%


the healthcare worker did not conduct

hand hygiene at all

4% 5% 2% 2%

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Table 4: Results for facilities, services, and units that conducted Self Audits, October – December

2017

Area Overall hand hygiene

compliance

Percentage of observations in which the healthcare worker

wore jewellery

Percentage of observations in which the healthcare worker had artificial nails/nail

polish

Acquired Brain Injury Outreach Team

100% 0% 0%

Central Primary Health Care Network

98% 2% 0%

Communicable Disease and Sexual Health

100% 0% 0%

East Primary Healthcare Network

91% 2% 7%

EMS Indian Head 99% 0% 0%

EMS Regina 100% 0% 0%

EMS Rural 50% 0% 0%

EMS Whitewood 99% 1% 0%

Home Care – Palliative

95% 0% 0%

Home Care – Pediatric

97% 1% 1%

Home TPN 100% 0% 0%

Maternity Visiting Program

100% 0% 0%

Mental Health and Addictions – Child and Youth Services

98% 0% 1%

Mental Health Clinic (2110 Hamilton)

83% 17% 17%

15


compliance


wore jewellery


polish

North Primary Health Care Network

97% 1% 0%

PH – Ambulatory Care

100% 0% 0%

PH – Dermatology 100% 0% 0%

PH – Environmental Services

99% 0% 0%

PH – Nutrition and Food Services

94% 0% 0%

PH – Pharmacy 97% 3% 0%

PH – Porters 80% 0% 0%

PH – SWADD 90% 0% 0%

PH – Unit Support Workers

85% 8% 5%

Prairie East Primary Health Care Network

96% 1% 0%

RGH – Ambulatory Care

97% 0% 0%

RGH – Environmental Services

97% 0% 0%

RGH – Fetal Assessment

97% 0% 0%

RGH – Infectious Diseases

100% 0% 0%

RGH – MEDEC and Foot Health

96% 4% 1%

16


compliance


wore jewellery


polish

RGH – Mother Baby 92% 0% 0%

RGH – Pharmacy 100% 0% 0%

RGH – Porters 96% 0% 0%

RGH – SWADD 73% 0% 0%

RGH – Unit Support Workers

94% 0% 1%

RGH –Nutrition and Food Services

98% 0% 0%

RPV – ADSP/Therapies

59% 0% 0%

RPV – Environmental Services

93% 0% 3%

RPV – Nutrition and Food Services

100% 0% 0%

South Primary Health Care Network

100% 0% 0%

Specialty Immunization/Travel Health Clinic

100% 0% 0%

Touchwood Qu’Appelle Primary Health Care Network

98% 1% 0%

Twin Valleys Primary Health Care Network

96% 0% 0%

WRC – Environmental Services

100% 0% 0%

WRC – Nutrition and Food Services

100% 0% 0%

Overall 96% 1% 1%

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Figure 2: Hand hygiene compliance rates, Self-Audits, September – December 2017

18

FINAL REPORT – PATIENT CARE AUDITS

For October – December 2017, a total of 9553 hand hygiene observations were submitted for

analysis.

For the analysis of patient care audits, the following definition of hand hygiene was used:

Compliant:

1) Hand gel or wash, AND

2) A required time component of ≥ 15 seconds

Noncompliant:

1) Gloves only,

2) Missed hand hygiene opportunity,

3) Hand gel or wash with a time component of < 15 seconds,

4) Jewellery, and/or

5) Artificial nails/nail polish

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Table 5: Regional hand hygiene audit results, Patient Care Audits, September - December 2017

Measurement

September 2017

October 2017 November 2017 December 2017





healthcare worker wore jewellery 1% 1% 1% 1%


healthcare worker had artificial nails/nail

polish

1% 1% 1% 1%


healthcare worker did not conduct hand

hygiene at all

11% 18% 16% 16%

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Figure 3: Hand hygiene compliance rates, Patient Care Areas, September – December 2017

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Figure 4: Hand hygiene compliance, by facility, Patient Care Areas, October – December 2017

22

Figure 5: Hand hygiene compliance, by Healthcare Worker, Patient Care Areas, October – December 2017

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Figure 6: Hand hygiene compliance, Regina General Hospital, Patient Care Areas, October – December 2017

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Figure 7: Hand hygiene compliance, Pasqua Hospital, Patient Care Areas, October – December 2017

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Figure 8: Hand hygiene compliance, Wascana Rehabilitation Centre, Patient Care Areas, October – December 2017

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Figure 9: Hand hygiene compliance, Regina Pioneer Village, Patient Care Areas, October – December 2017

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ALL NATIONS HEALING HOSPITAL

October – December 2017

Red line = Hand hygiene compliance

Green Line = Hand hygiene target

Did not participate

28

BALCARRES INTEGRATED CARE CENTRE

OCTOBER – DECEMBER 2017



Jewellery not allowed = 0%

Nails not allowed = 1%

29

BROADVIEW CENTENNIAL LODGE






30

BROADVIEW UNION HOSPITAL






31

CENTRAL PRIMARY HEALTH CARE NETWORK






32

CUPAR AND DISTRICT NURSING HOME






33

ECHO LODGE






34

ELMVIEW EXTENDICARE






35

GOLDEN PRAIRIE HOME






36

GRENFELL HEALTH CENTRE






37

GRENFELL PIONEER HOME






38

INDIAN HEAD UNION HOSPITAL






39

KIDNEY HEALTH CENTRE






40

LONG LAKE VALLEY INTEGRATED CENTRE






41

LUMSDEN HERITAGE HOME




Did not participate in November 2017



42

MENTAL HEALTH AND ADDICTIONS TREATMENT CENTRE






43

MENTAL HEALTH CLINIC 2110 HAMILTON 3RD FLOOR






44

MONTMARTRE HEALTH CENTRE






45

NATIVE HEALTH SERVICES






46

PARKSIDE EXTENDICARE

October – December 2017



Did not participate

47







48







49







50







51







52







53







54







55







56

PASQUA HOSPITAL – C.T.






57

PASQUA HOSPITAL – CARDIO/NEURO DIAGNOSTICS






58

PASQUA HOSPITAL – DAY SURGERY






59

PASQUA HOSPITAL - EMERGENCY






60

PASQUA HOSPITAL – EYE CENTRE






61

PASQUA HOSPITAL - ICU






62

PASQUA HOSPITAL – LABORATORY & PHLEBOTOMY






63

PASQUA HOSPITAL - MAMMOGRAPHY






64

PASQUA HOSPITAL - MSU






65

PASQUA HOSPITAL – NUCLEAR MEDICINE






66

PASQUA HOSPITAL - OR






67

PASQUA HOSPITAL - PACU






68

PASQUA HOSPITAL – RESPIRATORY THERAPY




Did not participate in November and December 2017



69

PASQUA HOSPITAL – SHORT STAY




Did not participate in October 2017



70

PASQUA HOSPITAL – THERAPY SERVICES




Did not participate in October and December 2017



71

PASQUA HOSPITAL - ULTRASOUND






72

PASQUA HOSPITAL – X-RAY






73

QU’APPELLE HOUSE






74

REGINA CENTRE CROSSING - FMU




Did not participate in October and November 2017



75

REGINA CENTRE CROSSING – SURGICAL ASSESSMENT CENTRE






76

REGINA LUTHERAN HOME






77

REGINA GENERAL HOSPITAL – 0D/1D






78







79

REGINA GENERAL HOSPITAL – 4B






80







81







82







83







84








85







86

REGINA GENERAL HOSPITAL - ANGIO






87

REGINA GENERAL HOSPITAL – C.T.






88

REGINA GENERAL HOSPITAL – CARDIO/NEURO DIAGNOSTICS






89

REGINA GENERAL HOSPITAL – CATH LAB






90

REGINA GENERAL HOSPITAL - CCU






91

REGINA GENERAL HOSPITAL - CSU






92

REGINA GENERAL HOSPITAL – DAY SURGERY






93

REGINA GENERAL HOSPITAL - EMERGENCY






94

REGINA GENERAL HOSPITAL - ENDOSCOPY






95

REGINA GENERAL HOSPITAL – LABORATORY & PHLEBOTOMY






96

REGINA GENERAL HOSPITAL – LABOUR & BIRTH






97

REGINA GENERAL HOSPITAL - MDRU






98

REGINA GENERAL HOSPITAL - MICU






99

REGINA GENERAL HOSPITAL - MRI






100

REGINA GENERAL HOSPITAL - NICU






101

REGINA GENERAL HOSPITAL – NUCLEAR MEDICINE






102

REGINA GENERAL HOSPITAL - OR






103

REGINA GENERAL HOSPITAL - PACU






104

REGINA GENERAL HOSPITAL – PEDIATRIC OUTPATIENT






105

REGINA GENERAL HOSPITAL – PULMONARY FUNCTION




Did not participate in December 2017



106

REGINA GENERAL HOSPITAL - RENAL






107

REGINA GENERAL HOSPITAL – RESPIRATORY THERAPY




Did not participate in November and December 2017



108

REGINA GENERAL HOSPITAL – SHORT STAY UNIT







109

REGINA GENERAL HOSPITAL - SICU






110

REGINA GENERAL HOSPITAL - THERAPIES







111

REGINA GENERAL HOSPITAL - ULTRASOUND






112

REGINA GENERAL HOSPITAL – WOMEN’S HEALTH






113

REGINA GENERAL HOSPITAL – X-RAY






114







115







116







117







118







119

REGINA PIONEER VILLAGE – HOSTEL






120

REGINA PIONEER VILLAGE – MAIN WEST






121

SANTA MARIA






122

SILVER HEIGHTS SPECIAL CARE HOME






123

SOUTHEAST INTEGRATED CARE CENTRE – ACUTE CARE






124

SOUTHEAST INTEGRATED CARE CENTRE - LTC






125

SOUTHEAST INTEGRATED CARE CENTRE - DIAGNOSTICS






126

ST. JOSEPH’S INTEGRATED CARE CENTRE






127

SUNSET EXTENDICARE







128







129







130







131







132







133







134

WASCANA REHABILITATION CENTRE – ADULT THERAPIES






135

WASCANA REHABILITATION CENTRE – CHILDREN’S PROGRAM






136

WASCANA REHABILITATION CENTRE - FRP






137







138







139

WASCANA REHABILITATION CENTRE – ORTHOTICS & PROSTHETICS






140

WASCANA REHABILITATION CENTRE - RENAL






141

WASCANA REHABILITATION CENTRE – RESP (2-6)







142

WHITEWOOD COMMUNITY HEALTH CENTRE






143

WILLIAM BOOTH SPECIAL CARE HOME






144

WOLSELEY MEMORIAL INTEGRATED CARE CENTRE






table of contents - regina qu'appelle health region · cupar and district nursing home . 2...

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