Patient Safety Indicators

Infection Prevention and Control

Lake of the Woods District Hospital priority is to ensure quality patient care and safety through transparency. Our infection control program is in place to ensure that our patients are not at risk for contracting health care-associated infections, and we are committed to transparency by using provincial standardized patient safety data collection and public reporting.

It is important to understand that the reporting of these rates is not the solution to reducing the rates of healthcare associated infections. This gives us data and information in understanding where patient safety issues may exist and take action to improve.

 Click on the links below to view our reports on eight patient safety indicators that are measured by Ministry of Health and Long-Term Care.

Click here to find Health Quality Ontario patient safety indicator reports

 

Safe Surgery Saves Lives

Safe Surgery Saves Lives Checklist (SSSL) - Public Reporting Calendar:

What is a surgical safety checklist?
 
Patient safety remains the most important priority for Lake of the Woods District Hospital, and this involves ensuring a safe experience for patients who undergo surgery here. Our patients can expect safe, high quality care, and one tool we use to help ensure a positive patient care experience is a surgical safety checklist.
 
A surgical safety checklist is a patient safety communication tool that is used by our team of operating room professionals (nurses, surgeons, anesthesiologists, and others) to discuss important details about each surgical case. In many ways, the surgical checklist is similar to an airline pilot’s checklist used just before take-off. It is a final check prior to surgery used to make sure everyone knows the important medical information they need to know about the patient, all equipment is available and in working order, and everyone is ready to proceed.
 
Essentially, the checklist is about improving overall teamwork – a critical factor in producing positive clinical outcomes. There is a lot of work being done in Ontario right now to improve patient safety, and the surgical safety checklist is one component.
Lake of the Woods Reporting Data on use of the Surgical Safety Checklist
2010 Checklist
Use Reporting Period
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
                         
# of Surgical Cases Reported N/A N/A N/A 175 225 199 630 170 212 160
# of Cases SSSL Checklist Used       175 225 199 630 170 212 160
% Compliance       100% 100% 100% 100% 100% 100% 100%
              Next Reporting Period July To Dec
 
2011 Checklist
Use Reporting Period
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
                         
# of Surgical Cases Reported 222 165 199 250 225 188  226  163  225  177  255  178
# of Cases SSSL Checklist Used  222  165  199 250 225 188  226  163  225  177 255  178
% Compliance  100%   100%  100%   100%  100% 100% 100%  100% 100%  100% 100% 100%
                         
2012 Checklist
Use Reporting Period
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
                         
# of Surgical Cases Reported 215 204 216 193 230 202 232 145 205 217 210 132
# of Cases SSSL Checklist Used 215 204 216 194 231 203 232 145 205 217 210 131
% Compliance 100% 100% 100% 99% 99% 99%  100% 100% 100% 100% 100% 99%
                         
2013 Checklist
Use Reporting Period
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
                         
# of Surgical Cases Reported 241 187 213 218 204 160 257 222 189 213 180 171
# of Cases SSSL Checklist Used 240 187 213 217 204 160 257 222 189 213 180 171
% Compliance 99.5% 100% 100% 99.5% 100% 100% 100% 100% 100% 100% 100% 100%
                         
Explanation of content of Safe Surgery Saves Lives Checklist and method of calculations
 
          DESCRIPTION OF REPORT
 
 
“The percentage of surgeries in which a Surgical Safety Checklist was performed”                                                   Public Hospitals Act Section 22.2 Regulation 965                                                                                                                                            
                                                                               “Patient safety indicators disclosure”
      
         METHOD OF CALCULATION:
                      (Number of Times ALL 3 PHASES of the SSCL was performed X 100)
                                          Total number of surgeries per month
                                                            = % COMPLIANCE   
 
DEFINITION OF A COMPLETED SURGICAL SAFETY CHECKLIST
 
 
“The SSCL is considered performed when the checklist coordinator confirms that surgical team members have implemented and /or addressed all the necessary tasks and items of the checklist IN EACH OF THE THREE PHASES “Briefing / Time Out / Debriefing”
 
DEFINITION OF EACH PHASE
 
Briefing:      Before anesthesia is administered
Time out:     Before commencing surgery
Debriefing:   Before leaving the operating room
 
WHAT INFORMATION IS INCLUDED IN EACH PHASE:
 
Some examples of items contained in the checklist:
 
The Briefing Phase:
• Verify with patient name and procedure to be done
• Allergy Check
• Medications Check
• Operation site, side and procedure
• Lab tests, xrays
* Blood type and availability
* Confirmation of special equipment required for the surgery
 
The “Time Out” Phase:
Last “double check” to ensure correct site of surgery
• Patient position
• Operation site and side and procedure
• Antibiotics check
 
The Debriefing Phase:
• Surgeon reviews important items
• Anesthesiologist reviews important items
• Nurse reviews correct counts
* Patient’s recovery plan evident to all involved.
 
 
WHERE CAN THE PUBLIC ACCESS THIS INFORMATION FOR THE PROVINCE:
 
 
Each Ontario hospital will have this information available on their hospital website
In addition, the MOHLTC will also report the same information on its website www.ontario.ca/patientsafety
 

All Rates

Here are all of the Patient Safety Indicator Results, on a single page. For more information on an individual result/calculation, please click on the result title in the menu on the left.

Hand Hygiene

As of April 30, 2009, all Ontario hospitals are required to annually post their hand hygiene compliance rates to further promote accountability and transparency within the health system.

Hand hygiene is an important practice for health-care providers but also involves everyone in the hospital, including patients, families and visitors.
 Effective hand hygiene practices in hospitals play a key role in preventing the spread of health care-associated infections.

Hand hygiene compliance is calculated by taking the number of times that hand hygiene was performed before initial patient /patient environment contact and after patient /patient environment contact and is divided by the number of observed hand hygiene indications for that specific indication. The results are then multiplied by 100. This calculation represents the percentage compliance rate for hand hygiene.

Hospitals are to collect at least 200 observations for every 100 inpatient beds.

Lake of the Woods District Hospital has implemented the provincial Just Clean Your Hands campaign. It is important to note that Lake of the Woods District Hospital was involved in the pilot of this significant program.

The collection and public reporting of these rates will allow hospitals to establish a baseline from which to track their hand hygiene improvement over time. Hospitals will use this information to identify areas for improvement and strategies for reducing the incidence of health-care-associated infections.

Why is hand hygiene so important?
Hand hygiene is an important practice for health care providers and has a significant impact on reducing the spread of infections in hospitals. Hand hygiene is a different way of thinking about safety and patient care and involves everyone in the hospital, including patients and health care providers.

Effective hand hygiene practices in hospitals play a key role in improving patient and provider safety, and in preventing the spread of health care-associated infections.

What is hand hygiene?
Hand hygiene relates to the removal of visible soil and the removal or killing of transient microorganisms from the hands and may be accomplished using soap and running water or an alcohol-based hand rub.  

Why is hand hygiene compliance one of the publicly reported indicators?
The single most common transmission of health care-associated infections (HAIs) in a health care setting is via transiently colonized hands of health care workers who acquire it from contact with colonized or infected patients, or after handling contaminated material or equipment. Monitoring hand hygiene practices and the provision of timely feedback are vital to improving compliance and, in turn, reducing HAIs.

What will be publicly reported for Hand Hygiene?
Each hospital is required to submit compliance data to the Ministry of Health and Long-Term Care (Ministry) on all four indications for hand hygiene.   Hospitals are required to post, by site, the percent compliance rates for each period end date on their corporate websites. Hospitals will post the compliance rate for:
 (i) hand hygiene before initial patient/patient environment contact by combined health care provider type
(ii)  hand hygiene after patient/patient environment contact by combined health care provider type
The Ministry will also report the above data, by hospital site, on its website (www.ontario.ca/patientsafety).
How are the hand hygiene compliance rates calculated?
Hospitals will calculate the percent compliance for each of the four indications of hand hygiene as follows:

# of times hand hygiene performed before initial patient/patient environment contact     x 100
# observed hand hygiene indications for before initial patient/patient environment contact

# of times hand hygiene performed before aseptic procedure       x 100
# observed hand hygiene indications for before aseptic procedure

# of times hand hygiene performed after body fluid exposure risk         x 100
# observed hand hygiene indications for after body fluid exposure risk

# of times hand hygiene performed after patient/patient environment contact          x 100
# observed hand hygiene indications for after patient/patient environment contact

The Lake of the Woods District Hospital takes patient safety very seriously and this involves ensuring  that patients are not at risk for contracting healthcare-associated infections.
We have a number of practices in place to help prevent and control infections, including a comprehensive hand hygiene program.

If you have any questions about this information or about our hospital’s infection prevention and control program, please contact the Infection Prevention and Control Office at 468-9861 ext. 362.

What are health care-associated infections?
Sometimes when patients are admitted to the hospital, they can get infections. These are called health care-associated infections.

How will the public reporting of hand hygiene compliance affect compliance among health care professionals?
There are many factors that will improve hand hygiene compliance. Mandatory public reporting is one element. Certainly the increasing recent attention on the issue as well as the provincial government’s multifaceted hand hygiene program called Just Clean Your Hands are important to ensuring effective hand hygiene at the right times.

What can patients do to help improve their own safety?
Hand hygiene involves everyone in the hospital, including patients. Hand cleaning is one of the best ways you and your health care team can prevent the spread of many infections. Patients and their visitors should also practice good hand hygiene before and after entering patient rooms.

More patient-specific information is available at www.ontario.ca/patientsafety and www.oha.com/patientsafetytips.