Completing Yo r Q alit Completing Your Quality Improvement Plan

Part A ‐What the organization will be focusing on andhow these objectives and initiatives will be achieved• Aims & Measures ‐ By March 31st 2012, we will:• Reduce overall hospital mortality by 5% as measured by HSMR, andcontinue 5% reductions per year over the subsequent three years• Hold gains on certain infections (ventilator‐associated pneumonia andcentral line infection at zero)• Attain 90% compliance on hand hygiene, and be in the top 10% for Cdifficile infection rates (0.15 per 1000 bed‐days) y)• For heart attack care, sepsis and prevention of blood clots: increasecompliance from 70% to 90% on adherence for best practices (i.e. gettingthe right drug, test or treatment at the right time).40