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Based on staff interview, the review of 2011 and 2012 QAPI (Quality Assessment & Performance Improvement) documentation, review of Infection Control program documentation, and documentation for 1 of 4 QAPI indicators reviewed (Inpatient hand washing) for 2011 and 2012, it was determined the hospital failed to document a specific method which included the frequency of data collection for hand washing in all areas of the hospital.

Findings include:

1. The hospital's "Memorable Experience Dashboard December 2011" and "Memorable Experience Dashboard January 2012" reports were reviewed. The reports reflected the hospital's quality indicators and corresponding quarterly percentages for 2011 and the first quarter of 2012. Inpatient and outpatient hand washing indicators were identified under the headings" Inpatient Questionnaires" and "Outpatient Questionnaires."

2. An interview was conducted with the Director of Nursing & Emergency Services on 02/16/2012 at 1130. The director said it had been determined the most effective method for measuring staff compliance with hand washing was by gathering data from patient questionnaires for inpatient and outpatient areas. He/she said this decision was made approximately 3-4 years ago. The director was asked to provide documentation which described the specific method and frequency for monitoring hand washing and he/she provided a document titled "Outpatient Questionnaires" with a hand written date "2011 in review."

Review of the document "Outpatient Questionnaires" reflected "Outpatient questionnaires were developed by Department Directors to review patient perceptions regarding cleanliness, surroundings, wait time, patient safety and staff response...Questionnaires are given to every 7th outpatient, at the time of admission, by the admission staff...321 or .016% were returned during January 2011 to July 2011...Questions with 'No' answers...Lab (6) ED (4) Surgery (6) Imaging (5)..." The documentation did not include information regarding the specific method and frequency of data collection used by the hospital to monitor hand washing for inpatient areas.

3. An interview was conducted with the Infection Control Preventionist/Staff Development Coordinator on 02/16/2012 at 1050. The coordinator said that although the 2011 goal for hand washing was set at 80% in some hospital areas, the goal was to gradually increase to 100% hospital-wide. The coordinator reported experiencing challenges with the collection of meaningful data. Prior methods included monitoring the use of hand sanitizer dispensers, and the use of junior volunteers to collect the data. The coordinator said those methods were inaccurate and therefore the hospital began using patient questionnaires to monitor hand washing and gather the data. He/she further said it may not be realistic to achieve the hand washing goals because they were relying on the patient's perspective for the monitoring. He/she described the data collection as "very intermittent." The coordinator said there was no documented evaluation of whether or not patient questionnaires were an effective method for monitoring hand washing.

4. Review of the 2011 dashboard reflected the goal for hand washing in inpatient areas was >80%. Although the "YTD Average" was 94%, there was no documentation which indicated the specific method including the frequency of the data collected.

5. The "Santiam Memorial Hospital Committee Review 2011" was reviewed and included 2011 quality monitoring and activities for various hospital committees such as Infection Control, Surgery, Anesthesia & Tissue, and Performance Improvement. There was no documentation regarding hand washing monitoring or data collection which included a specific method and frequency.

6. The hospital's "Performance Improvement and Safety Plan 2012" was reviewed and reflected "...The 'Infection Control Performance Improvement Plan' outlines the committees quality review process." The "Performance Improvement and Safety Plan 2012" did not include plans for hand washing monitoring or data collection including a specific method and frequency.

7. The hospital's "Infection Control Committee Infection Control Plan 2012" was reviewed and reflected "ESTABLISHMENT OF INDICATORS...The Infection Control Committee has selected surveillance activities that include monitoring...Staff surveillance..." Although the 2011 and 2012 dashboard indicators included hand washing percentages for inpatient and outpatient areas, the infection control plan did not include on-going hand washing monitoring including a specific method and frequency. According to the interviews above, patient questionnaires had been used for 3-4 years to monitor and collect hand washing data. Staff had identified concerns with using patient questionnaires, however there was no documentation that the concerns had been evaluated or addressed in order to provide opportunities for improving the process.

8. An interview was conducted with the Director of Nursing & Emergency Services on 03/07/2012 at 1640. He/she indicated that hand washing activities should be in the infection control plan. He/she also indicated that documentation of the specific method and frequency for hand washing data collection may be located in meeting minutes from several years ago. An opportunity to provide additional documentation was provided. No further documentation was received.

Based on staff interview, the review of 2011 and 2012 QAPI (Quality Assessment & Performance Improvement) documentation, review of Infection Control program documentation, and documentation for 1 of 4 QAPI indicators reviewed (Inpatient hand washing) for 2011 and 2012, it was determined the hospital failed to document a specific method which included the frequency of data collection for hand washing in all areas of the hospital.

Findings include:

1. The hospital's "Memorable Experience Dashboard December 2011" and "Memorable Experience Dashboard January 2012" reports were reviewed. The reports reflected the hospital's quality indicators and corresponding quarterly percentages for 2011 and the first quarter of 2012. Inpatient and outpatient hand washing indicators were identified under the headings" Inpatient Questionnaires" and "Outpatient Questionnaires."

2. An interview was conducted with the Director of Nursing & Emergency Services on 02/16/2012 at 1130. The director said it had been determined the most effective method for measuring staff compliance with hand washing was by gathering data from patient questionnaires for inpatient and outpatient areas. He/she said this decision was made approximately 3-4 years ago. The director was asked to provide documentation which described the specific method and frequency for monitoring hand washing and he/she provided a document titled "Outpatient Questionnaires" with a hand written date "2011 in review."

Review of the document "Outpatient Questionnaires" reflected "Outpatient questionnaires were developed by Department Directors to review patient perceptions regarding cleanliness, surroundings, wait time, patient safety and staff response...Questionnaires are given to every 7th outpatient, at the time of admission, by the admission staff...321 or .016% were returned during January 2011 to July 2011...Questions with 'No' answers...Lab (6) ED (4) Surgery (6) Imaging (5)..." The documentation did not include information regarding the specific method and frequency of data collection used by the hospital to monitor hand washing for inpatient areas.

3. An interview was conducted with the Infection Control Preventionist/Staff Development Coordinator on 02/16/2012 at 1050. The coordinator said that although the 2011 goal for hand washing was set at 80% in some hospital areas, the goal was to gradually increase to 100% hospital-wide. The coordinator reported experiencing challenges with the collection of meaningful data. Prior methods included monitoring the use of hand sanitizer dispensers, and the use of junior volunteers to collect the data. The coordinator said those methods were inaccurate and therefore the hospital began using patient questionnaires to monitor hand washing and gather the data. He/she further said it may not be realistic to achieve the hand washing goals because they were relying on the patient's perspective for the monitoring. He/she described the data collection as "very intermittent." The coordinator said there was no documented evaluation of whether or not patient questionnaires were an effective method for monitoring hand washing.

4. Review of the 2011 dashboard reflected the goal for hand washing in inpatient areas was >80%. Although the "YTD Average" was 94%, there was no documentation which indicated the specific method including the frequency of the data collected.

5. The "Santiam Memorial Hospital Committee Review 2011" was reviewed and included 2011 quality monitoring and activities for various hospital committees such as Infection Control, Surgery, Anesthesia & Tissue, and Performance Improvement. There was no documentation regarding hand washing monitoring or data collection which included a specific method and frequency.

6. The hospital's "Performance Improvement and Safety Plan 2012" was reviewed and reflected "...The 'Infection Control Performance Improvement Plan' outlines the committees quality review process." The "Performance Improvement and Safety Plan 2012" did not include plans for hand washing monitoring or data collection including a specific method and frequency.

7. The hospital's "Infection Control Committee Infection Control Plan 2012" was reviewed and reflected "ESTABLISHMENT OF INDICATORS...The Infection Control Committee has selected surveillance activities that include monitoring...Staff surveillance..." Although the 2011 and 2012 dashboard indicators included hand washing percentages for inpatient and outpatient areas, the infection control plan did not include on-going hand washing monitoring including a specific method and frequency. According to the interviews above, patient questionnaires had been used for 3-4 years to monitor and collect hand washing data. Staff had identified concerns with using patient questionnaires, however there was no documentation that the concerns had been evaluated or addressed in order to provide opportunities for improving the process.

8. An interview was conducted with the Director of Nursing & Emergency Services on 03/07/2012 at 1640. He/she indicated that hand washing activities should be in the infection control plan. He/she also indicated that documentation of the specific method and frequency for hand washing data collection may be located in meeting minutes from several years ago. An opportunity to provide additional documentation was provided. No further documentation was received.