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Quality Improvement Committee Report. Surgical Services 2011-2012. James F. Harrington, Director. Surgical Services Department units:. Ambulatory Care Services Operating Room Post Anesthesia Recovery Unit Central Sterile Reprocessing. 2011-2012 Quality Improvement Initiatives. - PowerPoint PPT Presentation
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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