The IMPACT Quality & Safety Council, led by Chair Lois Chen, BSN, RN, CCRN, and Chair-Elect Reichel Dizon, BSN, RN, with the support of their Advisor, Clinical Quality Director Alma Domingo, MSQA, BSN, RN, CPHQ, CLSSBB, aimed to reduce Clostridioides difficile (C. diff) infection rates at the medical center.

Using the SMART goal framework, the council analyzed the root causes of C. diff fallouts and discovered that delays in documentation and incomplete handoffs during patient transfers or changes were major contributors. To address these issues, the council developed two SMART goals directly aimed at reducing C. diff infections:

1. San Leandro Medical Center will have a 10% reduction in C. Diff cases from the year 2024 to year end 2025. This will be done by improving the ED RN to inpatient RN handoff by adding loose stool section in the RN handoff tool.
2. San Leandro Medical Center will have a 10% reduction in C. Diff cases from the year 2024 to year end 2025. This will be done by improving the unit-to-unit RN handoff and standardizing SBAR to include the history of loose stools.

To support these goals, the handoff in both ED and unit teams was modified to include any history of loose stools. Through these efforts, San Leandro Medical Center ended 2025 surpassing the original goal. The council continues to implement strategies to ensure safe, high-quality care for our patients.