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Quality Improvement Committee Report

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.

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Quality Improvement Committee Report

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  1. Quality Improvement Committee Report Surgical Services 2011-2012 James F. Harrington, Director

  2. Surgical Services Department units: Ambulatory Care Services Operating Room Post Anesthesia Recovery Unit Central Sterile Reprocessing

  3. 2011-2012 Quality Improvement Initiatives • Surgical Care Improvement Program (SCIP) • Keystone Surgery Collaborative Goals • Infection Control • Patient Education • Customer Service

  4. SCIP Dashboard

  5. Surgical Care Improvement Program (SCIP)

  6. Keystone Quality Initiatives

  7. Keystone

  8. Keystone

  9. Infection Control (IC)

  10. 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

  11. 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

  12. Infection Control On Admission Surgical 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.

  13. Quality Customer Service

  14. Who is not 100% satisfied? Source: Arbor Associates 5/16/2012

  15. Quality in patient education Answers 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

  16. Quality Customer Service Infusion 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. I.ma. Nurse Henry C. Tech Benjamin Dover MD Anna Stesia CRNA

  17. Thank you

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