BC SCR Call

1. BC SCR Call November 2011

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

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

4. Surgical Quality Improvement: From the SCR Point of View Jennifer Ritz, RN November 10, 2011 BC NSQIP SCR Call

5. 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

6. Henry Ford Hospital • 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

7. HFH 2006 NSQIP Data

8. HFH 2006 NSQIP Data

9. The 5 Phases of NSQIP Grief Denial: My patients are sicker, my operations harder… Anger: (do we really need to give you an example?) 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. Sadness: Are we killing them? Do we really Suck? Acceptance: What should we do now? Help

10. 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”

11. “low hanging fruit” • VTE incidence, inconsistent prophylaxis

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

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

14. 2007 NSQP DATA HFH

15. 2007-2008 NSQIP Data HFH

16. 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

17. 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

18. What is Surgical QI? • Everything mentioned in the previous slides …………..and a whole lot more

19. Where Does the SCR Fit In? • Starts with Data (NSQIP, SCIP, Core Measures, Internal Data Sources) • Collection • Understanding • Interpretation • Transparency • Presentation • Dashboards/Control Charts

20. 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!

21. 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!)

22. They’re arrogant and disruptive They don’t have time They don’t understand quality/process They don’t care Why the Quality Department doesn't want to work with Surgeons

23. “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 Why Surgeons Don’t Participate in QI

24. 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

25. 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”

26. 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”

27. Questions?

28. 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

29. Liberating Structures (Marlies) • What did you like most? • Why did that method appeal to you? • I am trying “improv”!

30. Tips and Tricks PATOS Dr. Bruce Hall - “smells like, look like” MI check cardiac consults Open Wound penrose drain – “extra piece of rubber”

31. Tips and Tricks 30-day follow-up Check your hospital policy re: leaving personal information on answering machine Preop Information Rhonda Leiber – “information/documentation needs to be captured preoperatively and not to use postop documentation”

32. Tips and Tricks CPT Coding Mark 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”

33. November 29 Meeting Laptop should be able to connect to wifi check with your IT CPT Books or Encoder Pro Access

34. Q&A