Quality Improvement Committee Report

Quality Improvement Committee Report

Surgical Services 2011-2012

James F. Harrington, Director

Ambulatory Care Services

Operating Room

Post Anesthesia Recovery Unit

Central Sterile Reprocessing

Surgical Services Department units:

2011-2012 Quality Improvement Initiatives

Surgical Care Improvement Program (SCIP)

Keystone Surgery Collaborative Goals

Infection Control

Patient Education

Customer Service

SCIP Dashboard

Surgical Care Improvement Program (SCIP)

Measure CMS TJC

Priority Health

BCBSM

Jan Feb Mar

Prophylactic Antibiotic Received within One Hour

Prior to Surgical Incision 97% 100% 100% 100% n=9 100% n=13 94.4% n=18

Hip & Knee 100% 100% 100 % n=6 100% n=11 100% n=13

Colon 100% 100% 100% n=1 NA n=0 NA n=0

Hysterectomy 100% 100% 100% n=2 100% n=2 75% n=4

Prophylactic Antibiotic Selection 98% 100% 100% NA 100% n=9 100% n=13 100% n=17

Prophylactic Antibiotics Discontinued within 24

Hours after Surgery End Time 95% 100% 100% 100% n=9 100% n=9 100% n=17

Hip & Knee 100% 100% 100% n=6 100% n=11 100% n=13

Colon 100% 100% 100% n=1 NA n=0 NA n=0

Hysterectomy 100% 100% 100% n=2 100% n=2 100% n=4

Urinary Catheter removed on POD 1 or 2 NA 100% NA 87.5% n=8 91.7% n=12 100% n=15

Perioperative Temperature Management NA None NA 100% n=10 100% n=15 100% n=21

Patients on Beta Blocker Therapy Pre-admission

who Received Beta Blocker during the Perioperative

Period (24 hrs pre op -discharge from PARU)

94% 100% None 100% 100% n=4 100% n=9 100% n=7

Recommended VTE Prophylaxis Ordered 95% 100% 100% 100% 100% n=9 100% n=15 95.2% n=21

VTE Prophylaxis Timely 93%

100% 100% 100% 100% n=9 100% n=15 95.2% n=21

Keystone Quality

Initiatives

Surgical Specimen Defects Programs Percentage of Cases with Defects

Any Cases with Defects / Total Number of Cases

1/1/2011 - 12/31/2011

Keystone

Briefing Compliance Mecosta County Medical Center - Entire Surgery Team

1/1/2010 - 12/31/2011

Keystone

Infection Control(IC)

IC from the start

In 2011-2012 audits, education and follow-up concerning instrument sterile reprocessing was provided to:

MHS physician offices

Private practice surgeon offices

Involving the patient in the infection control process

Since the introduction of pre-surgical CHG wipes in the OBGYN offices there have been zero documented infections in 278 consecutive c-section surgeries. In the 8 years prior to their introduction the c-section infection rate averaged 3% annually (4/109).

Pre-operative

Surgical Site

Cleansing 

Instructions

IC statistics 03/2012

Infection Control On AdmissionSurgical Services continues to require all patients undergoing total joint replacement to perform a pre-op “scrub” of the surgical site upon admission. In July 2011 this practice was expanded to open orthopedic and arthroscopic procedures.

Quality Customer Service

0-17 Years 19-29 Years 30-44 Years 45-64 Years 65+ Years0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

7.8%

9.3%

5.0%4.1%

2.1%

15.7%

8.2%

5.9% 5.8%

2.5%

20102011

Who is not 100% satisfied?

Source: Arbor Associates 5/16/2012

Quality in patient educationAnswers to frequently asked questions on:

What to expect

How to be physically prepared

What to bring

Post-op pain and treatment options

Gives information on:

SCIP measures and how the patient can

become involved.

Medication safety (i.e. PCA usage)

Available post-op ancillary services

Family and specialty physician contact

information

Helpful Information About

Your Procedure

Questions? Call 231.592.4299

Quality Customer ServiceInfusion Therapy unit process development Labs completed prior to admission to

shorten therapy time. Patients requiring repeat visits are

admitted to the same location. Designated infusion nurses provide

consistency of care and help to build nurse/patient rapport.

Pre/post op patient contact form revision Simplified instructions that are easier

to understand and shorter when left on answering machines.

Thank you cards have had a positive impact on patients and staff.

Thank you for allowing us the opportunity to serve

you during your recent visit. We hope that you had aand were fully satisfied with your care.Sincerely,

The MCMC Surgical Services Team

I.ma.

Nurse

Anna Stesia

CRNA

Benjamin

Dover MD

Henry C.

Tech

Thank you