Sacred Heart Medical Center University District
Measure: Develop and test practices to prevent blood stream infections associated with venous catheters that will be fully implemented by January 1, 2010.

Time Period Ending:  3/31/2013

What We Are Doing:

We have fully implemented this goal in our facility. We measure our performance regularly through medical record review or direct observation. When performing below our goal, we implement improvement tools and methodologies to improve care. PDCA ("Plan-Do-Check-Act") is an iterative four-step problem-solving process that is typically used.


PLAN: In this step, we evaluate the problem and propose solutions. Examples include education, development or modifications of standardized protocols, creating "prompts" or reminders, and using beneficial technology.


DO: We then implement the new process(es). Often on a small scale if possible.


CHECK: Next we measure the new process(es) and compare the results against the expected results to ascertain any differences.


ACT: Finally, we analyze the differences to determine their cause and where to apply changes that will include improvement. When a pass through these four steps does not result in the need to improve, we refine the scope to which PDCA is applied until there is a plan that involves improvement. Improvement often involves multiple PDCA cycles.

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