With the implementation of LEAN education in 2014, some departments have used their LEAN projects for their Department QA reports. An example of a QA project submitted was from Diagnostic Imaging (Radiology). An Ultrasound (US) Tech attended the LEAN classes & monitored clinic patients who were sent to Radiology for exams. They sampled 17 patients & their wait time for their exams. Four of the patients were not registered before they were brought over from the clinic. Radiology observed that registered patients had an average wait time of 3.1 minutes. Patients that were not registered had an average wait time of 12.5 minutes.

Having customers registered provides excellent customer service and prevents long wait times. The long wait times also disrupts scheduled patient flows for both the clinic and radiology departments. If the patient is not registered, their results do not flow into their patient chart. Also, when registration does not occur, the radiology staff is unaware of what exam needs to be performed. This increases the patient's wait time for their exam.

The US Tech attended a Clinic meeting on 3/11/15. She provided education to the clinic staff on why it was important to have the patient registered before they walk the patient to Radiology. The month since that meeting, Radiology has not had any patients sent to them from the clinic without being registered. Wait times in Radiology have been reduced & the flow of the patients has improved in their department. Customer service for the patients has improved & the patient's results are flowing into their chart.

For the second year in a row, Barrett Hospital & HealthCare has been recognized on the Immunization Action Coalition Hepatitis B Birth Dose Honor Roll. On July 16, 2013, the Immunization Action Coalition (IAC) launched the Hepatitis B Birth Dose Honor Roll. The Honor Roll recognizes hospitals and birthing centers that have attained high coverage rates for administering hepatitis B vaccine at birth.

To be included in the Immunization Action Coalition's Hepatitis B Birth Dose Honor Roll, a birthing institution must have:

• Achieved, over a 12-month period, a coverage rate of 90% or greater for administering hepatitis B vaccine before hospital discharge to all newborns (regardless of weight), including those whose parents refuse vaccination.
• Implemented written policies, procedures, and protocols to protect all newborns from hepatitis B virus infection prior to hospital discharge. The following criteria are generally required, but exceptions may be made.
• Parents are informed about the importance of the hepatitis B vaccine birth dose and that it is recommended for all newborns.
• All newborns routinely receive hepatitis B vaccine after birth, before hospital discharge.
• A review is performed as to whether the correct screening test, hepatitis B surface antigen (HBsAg), was ordered for the mother during this pregnancy.
• The result of the mother's HBsAg screening test is reviewed. It is best, if at all possible, that the policy calls for review of a copy of the original HBsAg test result, and not a transcribed or hand-entered report
• An HBsAg blood test is ordered ASAP if an incorrect test was ordered on the mother or if no test result is included on her chart.
• Infants born to HBsAg-positive mothers receive hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth.
• Infants born to mothers whose HBsAg status is unknown receive hepatitis B vaccine within 12 hours of birth.
• Infants who weigh less than 2,000 grams and are born to mothers whose HBsAg status is unknown receive HBIG (in addition to hepatitis B vaccine) within 12 hours of birth.
• Routine newborn admission orders include a standing order to administer hepatitis B vaccine to all infants (similar to standing orders to administer Vitamin K and ophthalmic antibiotic).
• Notification of the state or local health department's perinatal hepatitis B prevention program is done prior to discharge (or as soon as known, if after discharge) for all mothers whose HBsAg test result is positive.

For information on how to apply for honor roll status visit: http://www.immunize.org/honor-roll/birthdose/