BC SCR CALLNOVEMBER 2011

Outline

• Jennifer Ritz – Henry Ford• Cheryl and Kerry - Royal Inland Hospital• Liberating Structures - Marlies• Tips and Tricks• November Meeting Reminders

Surgical Quality Improvement:From the SCR Point of View- Jennifer Ritz

Surgical Quality Improvement: From the SCR Point of View

Jennifer Ritz, RN November 10, 2011

BC NSQIP SCR Call

Henry Ford Hospital

903-bed tertiary care hospital, education and research complex located in Detroit's New Center area.

Multi-organ transplantation center Level 1 trauma center Accredited Chest Pain Center National Stroke Center >1,000 physician group practice 22,000 operations annually

Joined ACS NSQIP in June of 2006– No previous mechanism to measure surgical

outcomes

Collected data on General and Vascular Surgery

First ACS NSQIP Semi-Annual Report received in January 2007

Expanded to multispecialty NSQIP in 2008

Henry Ford Hospital

HFH

2006 NSQIP Data

2006 NSQIP Data

HFH

The 5 Phases of NSQIP Grief1. Denial: My patients are sicker, my operations

harder…

2. Anger: (do we really need to give you an example?)

3. Bargaining: Ok, let me look at that data, I can make some sense of it, its clearly flawed and only I can explain it to you.

4. Sadness: Are we killing them? Do we really Suck?

5. Acceptance: What should we do now? Help

What we did

Deep dives into the data – Utilized unadjusted reports– Identified “low hanging fruit”

Share the data– Explain what it means, where it comes from, why its

important Identify interested stakeholders/champions

– “surgical ownership”– “quality ownership”– “nursing ownership”– “anesthesia ownership”

“low hanging fruit”

VTE incidence, inconsistent prophylaxis

Comparison of HFH to NSQIP database: 5/29/06 – 12/1/06

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

HFH NSQIP

DVT

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

HFH NSQIP

PE

PercentPercent

Comparison of HFH to NSQIP database: 01/01/07 – 01/31/08

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

HFH NSQIP

DVT

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

HFH NSQIP

PE

PercentPercent

2007 NSQP DATA

HFH

2007-2008 NSQIP Data

HFH

What is Surgical QI?

NSQIP– Outcomes Data – Clinically Based– Risk Adjusted

RCA/QIT– Root Cause Analysis– Quality Improvement Teams

PDSA (Plan Do Study Act), LEAN, Six Sigma

What is Surgical QI?

Sentinel Events– When a sentinel event occurs, the accredited organization is

expected to conduct a timely, thorough and credible root cause analysis; develop at action plan designed to implement improvements to reduce risk; implement the improvements; and monitor the effectiveness of those improvements. The Joint Commission September 10, 2009

Creating/Amending Policies & Procedure – Match current practice – Not a cure for process improvement

Surgical M&M also known as S&M– “Shame & Maim”

Patient Safety

What is Surgical QI?

Everything mentioned in the previous slides …………..and a whole lot more

Where Does the SCR Fit In?

Starts with Data (NSQIP, SCIP, Core Measures, Internal Data Sources)– Collection– Understanding – Interpretation– Transparency – Presentation

Dashboards/Control Charts

Where Does the SCR Fit In?

Project Facilitation– Collaboration with Surgeon Champion, Quality

Liaisons, and Anesthesia– Liaison to Multiple Departments– Stakeholder Identification – Facilitator of Quality Initiatives– Process Design

Must be a multidisciplinary approach……the SCR cannot do it alone!

When?

No time like the present– Network with ACS NSQIP build relationships with

successful hospitals – Learn from peers – Ask Questions

Utilize Resources– Internal

Hospital resources, quality/risk, infection control

– External ACS Best Practices Hospitals within your collaborative (do not reinvent the wheel!)

Why the Quality Department doesn't want to work with Surgeons

They’re arrogant and disruptive

They don’t have time

They don’t understand quality/process

They don’t care

Why Surgeons Don’t Participate in QI

“The quality people are inept”– “They don’t understand

my practice”– “They can’t tell me how

to manage my patients”

Scheduling

Too busy “My patients are

sicker” Nothing in it for me

How to Implement Surgical QI

Start small (think big) Start with one project at a time

– Choose one Outcome to focus on– Celebrate successes

Use Best Practices– Collaborate within ACS NSQIP hospitals– System Hospitals

There’s Always Room for Improvement

If you are a “High Outlier” don’t worry there’s hope: lot’s of room for improvement

If you are a “Low Outlier” its not so easy being/staying great

If your in the middle: “Do you really want to be average”

Food for thought

Nobody is perfect even the “Low Outlier” hospitals….

Are you really that comfortable being in the middle?

Sometimes Quality is just a “good idea” vs. “evidence based”

Questions?

Royal Inland Hospital-Kerry Cardwell and Cheryl Sibbelee

How are we doing?– NSQIP Structure– SC and SCR relationship– Education– Data Quality Control– Early findings from our data– QI methodology

Liberating Structures (Marlies)

• What did you like most?• Why did that method appeal to you?• I am trying “improv”!

Tips and Tricks

PATOSDr. Bruce Hall - “smells like, look like”

MIcheck cardiac consults

Open Woundpenrose drain – “extra piece of rubber”

Tips and Tricks

30-day follow-upCheck your hospital policy re: leaving personal information on answering machine

Preop InformationRhonda Leiber – “information/documentation needs to be captured preoperatively and not to use postop documentation”

Tips and Tricks

CPT CodingMark Cohen - “For purposes of modeling, CPTs codes are grouped into a few hundred categories based on anatomy and complexity. Thus, groups are composed of similar but clearly not identical procedures…you are safe if you select a CPT that is clinically close – since the vast majority of times those CPTs will be included in the same CPT group”

November 29 Meeting

Laptop should be able to connect to wifi check with your IT

CPT Books or Encoder Pro Access

Q&A