SlideShare a Scribd company logo
1 of 51
Download to read offline
Highlights of our Journey
with ACS-NSQIP
Surrey Memorial Hospital

Surgeon Champion Call
August 2010
Data Quality Control
QI in NSQIP
Do we have to?
How ?
Who is responsible?
What is acceptable?
What`s the worst that could happen ?
Data Quality Control
SC and SCR meetings
SCR and Surgical Program Director meetings
Identify data errors
Multiple postop occurrences
Inpatient/Outpatients
Subspecialty
CPT Code
DOB
Wound Class
3.5

2.5

108.00
114.00
141.00
89.00
66.00
113.00
88.00
19.00
111.00
8.00
80.00
135.00
128.00
127.00
45.00
15.00
24.00
122.00
75.00
72.00
26.00
100.00
32.00
58.00
31.00
52.00
147.00
124.00
9.00
64.00
68.00
12.00
43.00
38.00
16.00
148.00
40.00
50.00
85.00
44.00
51.00
41.00
129.00
83.00
10.00
54.00
143.00
86.00
48.00
94.00
107.00
49.00
102.00
29.00
20.00
104.00
60.00
13.00
132.00
145.00
97.00
81.00
91.00
65.00
98.00
56.00
116.00
144.00
27.00
123.00
55.00
87.00
134.00
28.00
2.00
103.00
63.00
36.00
67.00
62.00
126.00
73.00
34.00
69.00
70.00
138.00
4.00
120.00
105.00
78.00
92.00
57.00
99.00
119.00
96.00
37.00
53.00
142.00
77.00
14.00
130.00
76.00
93.00
146.00
90.00
95.00
131.00
106.00
35.00
71.00
137.00
79.00
11.00
84.00
117.00
140.00
110.00
139.00
115.00
82.00
33.00
3.00
101.00
21.00
121.00
74.00
22.00
30.00
46.00
112.00
136.00
47.00
23.00
25.00
5.00
59.00
42.00
39.00
118.00
152.00
109.00
61.00

Overall Renal Complications

Includes General and Vascular Surgery Cases

4

Outlier status:

Needs improvement

Good outcomes

ACS-NSQIP Hospital ID Number

Poor outcomes

3

Our
Hospita

2

1.5

1

0.5

0
Data Quality Control
Case Detail Report
Data Quality Control
Data Quality Control
Data Quality Control
Date of Birth Errors
MM/DD/YYYY vs DD/MM/YYYY

Discharge Information
Multiple admissions
Multiple files on EMR for a single admission

Wound Classification Errors
15% error per cycle
Wound Classification Guidelines
Data Quality Control
Missing Data
Variables

Then

Now

Future

ASA

33%

2%

Height

37%

24%

Electronic
and
mandatory fields

Weight

9%

6%

OR Reports

Available 2-3
months after
OR

3-4 weeks

Smoking History
(ppy)

95%

30%

Enhanced preop
assessment

Labs
(Albumin)

79%

53%

Links with external
lab facilities

30-Day FF-up

92.1%

92.5%

Translation
Services

Synoptic
Reporting
Data Quality Control
Challenges
CPT Codes
*Discuss OR reports with Surgeon Champion
*CPT Code mapping on Validation Worksheet

ICD Codes
*Surgeon’s offices/MOA

Missing data
*Revised nurses notes, assessment forms,
anaesthesia record

30-day Follow-up
*Telephone script for NSQIP clerks
Database Design
Excel spreadsheet with trends and graphs for
each project
Quarterly updates
Formulas embedded in excel
Pivot tables
Access Database
Data Reporting and Sharing
Internal
Surgical Committee Meetings
OR Committee Meetings
Council of Chiefs
Chairs of Division
Newsletters
Intranet
Update – Teams

External
FHA
BCPSQC
Provincial and National
Other NSQIP participating sites
Data Reporting and Sharing
Education
Learning Sessions
Surgical Safety Collaborative Meetings
In-service for frontline nurses
Directors, executives and physicians
New surgeons
Posters
Input/Output
2007 Semiannual Report
OE trend over time
Action Time
Postoperative Pneumonia
OE

Raw Data – trend over time
Rate/100 Surgical Procedures

Incidence of Pneumonia from
Jan 2007- Mar 2010

SMH
NSQIP

6%
5%
4%
3%
2%
1%
0%
Jan-Jun 2007

Jul-Dec 2007

Jan-Jun 2008

Jul-Dec 2008

Jan-Jun 2009

Jul-Dec 2009

Jan-Mar 2010
Postoperative Pneumonia
More Data
Emergency vs elective
Pneumonia Occurrence Emergent vs Elective
10%
8%
Rate

SMH Emergent
6%

NSQIP Emergent

4%

p-value <.0001

SMH Elective
NSQIP Elective

2%
0%
Jan-Jun 2008

Jul-Dec 2008

Jan-Jun 2009

Date

Pneumonia

RTO

2008

39 days

25 days

59 days

14 days

2008

31%

20%

2009

Mortality

Elective

2009

LOS

Emergent

23%

20%

2008

23%

10%

2009

15%

0%
Postoperative Pneumonia
More Data

Emergent surgeries
postop ventillation = 20/40 (50%)
postop ventillation + positive culture = 19/40 (48%)

Bugs were identified
Candida Albicans excluded
Pneum
onia Occurrence Em
ergent vs Elective
10%
8%

SMH Electiv
e
6%

NSQIP Electiv
e
SMH Emergent

4%

NSQIP Emergent

2%
0%
Jan-Jun 2008

Jul-Dec 2008

Jan-Jun 2009
Postoperative Pneumonia Prevention
Surrey Memorial Hospital
Team Goal:

Improvement Strategies

*NSQIP

data results July-Aug 2008:
3.4% Occurrence Rate

Pn
eum
onia Occurrence Tren Over Tim
d
e
Gen
eral and Vascular Surgeries

• Mobilization
- Dangle post op day 0 if tolerated or HOB elevated
- Increase activity as tolerated: Up to chair, walk X 1,2,3 etc.
• Meticulous Hand Hygiene
- Prevents transmission of micro-organisms between patients
- Infection control involvement on team
• Elevate Head of the Bed 30-40 Degrees
- HOB elevation during transport, post op bed or stretcher
- Rationale: Improves ventilation
- Prevents aspiration of stomach & nasopharyngeal secretions
Deep Breathing and Coughing Exercises
- Rationale: Improves ventilation and prevents atelectasis
- Assists with movement & expectoration of secretions
• Chlorhexidine Gargle
- Pre & post op oral decontamination
- Evidence indicates may decrease pneumonia rates post
surgery
Education & Support
- Patient and Family Education – Posters in rooms
“Prevent Pneumonia” coaching & education pre-& post
surgery for deep breathing & coughing
- assisting with mobilization
- encouraging self-care in recovery period post
surgery
- Staff Education – Huddles, emails, staff meetings, clinical
update, new staff orientation

Spot Check
Pneumonia Prevention
Action Team
Chart#__ ____ ____ Date_ ____ ____ ___

COMPLETE In Patient’s Room:
HOB elevated 30-40 degrees :
Yes No
N/A
Patient mobilized day 0:
Yes No
N/A
Patient dangled for 5 minutes X 1
Yes No
N/A
Or: HOB up 40 degrees for 5
minutes
Yes No
N/A

Preadmission
•Pre-op Education Pamphlet
with Pneumonia Prevention
Tips
•Encouraging Partnership
in Care
•Changes in Standard Orders
for Preoperative Oral
Decontamination

6%
5%
4%
%

To decrease the incidence of
pneumonia in postop bowel surgery
patients by 50% using NSQIP by
October 2009.

SMH

3%
2%
1%
0%

NSQIP

07 6-12/0
/0
6

0
1/07-06
/07 07/07 2/07 0
-1
1/08-0
6/08 07/08
-11/08
Dates

Risk-Adjusted Pneumonia with Comparison
to Other NSQIP Sites
Observed Rate: 2.73%
Expected Rate: 1.68%
O/E Ratio: 1.62
Status: As Exp ected

Spot Checks:
Pre -Implementation
October 2008: 50% HOB elevated
February 2009: 71% HOB elevated

Future Opportunities
• Bowel Resection Carepaths
• Changes in Preprinted Orders Reflecting
Initiatives
• Preadmission Education Pamphlets Revision
Focusing on Self-Management
• Spread and Integration of Bundles in Other
SMH Units and FHA Sites

TEAM MEMBERS
Linda Coleman, PT
Margaret Dyka-Gluzak, RN
Linda Nelson, Educator
Anne Edmond RN
Irene Harder, RN
Brenda Smith, RN
Melissa Idle, Physio
Raj Pandey, PT
Angela Wilson
RN
Christine
Donald, RN
Angela Tecson, SCNR
Sharon Parent, QI
Donna Rolph, Manager

3 South Surgical Front Line Staff
PDSA Cycles – Best Practices Audits
Pneumonia Prevention Audit
100%
HOB Elevated

60%

DBC Teaching

40%

DB&C Exercises
Mobility Documentation

20%
0%
Jun-09

Jul-09

Aug-09

Date of Audit

Mobility Postop Day #0
Colorectals
100%
80%
Rate

Rate

80%

HOB

60%

Dangle

40%

Walk

20%
0%
Jun-09

Jul-09

Aug-09

Date of Audit

Sep-09
Postoperative UTI
CAUTI Prevention Action Team
Surrey Memorial Hospital

Team Goal:

Improvement Strategies

As determined by frontline staff

Initiation: reach 80% of staff
8 x 30 min education
sessions (UTI Jeopardy)

Picture

4 x 10 min unit based
education (create
awareness)
Creation of prompts to
stimulate awareness

Sustainability
Daily reminders with
morning rounds
Kardex Inserts
Weekly spot checks led by
frontline staff - continuing
awareness for practice
changes
UTI Section to Initiative
wall with current data of
CAUTI infection rates on
Unit
CAUTI huddles – in
presence of UTI infections

U & I can
eliminate UTI’s
Actions;
2 person insertion & use smallest possible french
Prewash perineal area & use chlore hexdine 2%
swabs
Secure safely (to unaffected side if limb trauma)
No droopy Loops (ke ep between bladder and bag)
Keep bag below the bladder and off the floor
Label drainage container with name and date
Rinse after every drain and discard q24hrs
(0600)
Always ask, why is this catheter in? Don’t forget...
“2 Days Too Long”
For everyday the catheter is in place, please assess,
document;
Reason why catheter is in place
Has any follow up/ trial been done re: removal of
catheter
What is the plan for removal
Is the patient exhibiting any signs and symptoms
of UTI?

If UTI suspected send C+S, and notify MD.

After catheter removal,mobilize,hydrate patient &
provide bowel care. If patient is unable to void
follow these steps;

consider the type of surgery, pt medical status and
orders.…
I/O catheter for volume >400cc, x 2

Obtaining Results
then,

if still unable to void

Foley Catheter overnight and remove in AM
If problem persists, consider urology consult

1. Silver Catheters:
Insertion documented
in chart, Kardex and
tracking tool. Follow up
audit to be done.

2. Practice Changes:
weekly spot checks led
by frontline staff.

3. CAUTI Rates:
5 patients with
catheters (selected
from weekly spot
check) to be audited on
weekly basis

General and Vascular Surgeries

Process Change
UTI T rend Over Time

1.Trial of silver impregnated catheter
In OR: insertion of silver catheters in bowel
procedures
On Unit: pre-operative insertion of silver catheters in
the fractured hip population
Practice Changes
1. Insertion
2 person insertion
Pre-wash perineal area
CHG 2% for aseptic urinary meatus cleaning
Statlock securement to unaffected leg
2. Maintenance
No droopy loops (dependant loops)
Drainage bag between bladder and floor
New drainage container q 24hrs
Rinse drainage container after each drain
3. Removal
“2 Days too Long” : Removing a urinary catheter at
max post op day 2 at 0600 unless contraindicated
If catheter remains in place: documenting reason for
catheter and plan of care
Encourage activities to promote voiding: Mobility,
Hydration, Bowel care, Relaxation

4
3
%

Decrease Catheter Associated
Urinary Tract Infection rates 50% in
the fractured hip population by June
2009

UTI Trend Over Time

SMH

2

NSQIP
1
0
01 /06-06 /06

0 7/0 6-1 2/06

0 1/07 -0 6/07

07 /0 7-12 /0 7

01/0 8-06/0 8

0 7/08 -1 1/08

Dates

Risk-Adjusted Overall Urinary Tract Infections
with Comparison to Other NSQIP Sites
Observed Rate: 2%
Expected Rate: 1.34%
O/E Ratio: 1.49
Status: As Exp ected

Future Opportunities
1. Clinical decision making for Catheter reinsertion (i.e.
bladder scan volume - what is acceptable? When
does a catheter need to be inserted?) Align with HPA.
1. Continue with Silver Catheter trial and determine
sustainability of long term use
1. Spread of CAUTI Prevention action items throughout
the site. Initial spread to General Surgical Unit and the
surgical program.

Team Members :
Jyotika Prasad
Nen Graces
Sharon Parent
Jane Mann

Felicia Laing
Loretta Castelino
Nicole Quilty
Cindy Yazlovsky

Linda Jennings
Racheal Bertram
Elizabeth Allan
Angela Tecson

3S Surgical Orthopaedic Frontline Staff!!
PDSA Cycle
Orthopedic Ward – Silver Catheter Audit
UTI TREND OVER TIME

n

40
20
0
Apr-09

May-09

Jun-09

Apr-09

May-09

Jun-09

Ag Cath w/ UTI

0

0

0

Ag Cath

7

3

2

Reg Cath

18

13

6

Reg Cath w/ UTI

7

2

0

GS Ward – Catheter care audit
Baseline
Sept 2009

Nov 2009

Statlock on

100%

100%

Plan for removal

50%

50%

Droopy loops

100%

100%

Bag above the bladder

0%

0%

Bag on the floor

0%

0%

Drainage container dated

0%

0%

Catheter LOS (ave)

5 days

3.5 days
Total Number of Cases
Cases with SSI
3

0
Lymphadenectomy/Other

0

Immediate

2

Reconstruction

14

Mastectomy with

3

Modified, Radical

12

Mastectomy, Complete,

15

Mastectomy, Partial

16

Breast Mass Excision

Gynecomastia

4
2

Mastectomy for

Number of Cases

Surgical Site Infection

From bowels to breasts

SSI Rates According to Type of Breast Surgery

14
14

10
10

8

6

0
2
1

0
Surgical Site Infection Initiatives
Safer Healthcare Now
Preop antibiotic
Warm air/blanket
Appropriate hair removal

Antibiotic timing/redosing
Normothermia

World Health Organization - Surgical Safety Checklist
Briefings, Crew Resource Management
Preadmission
Patient Education – Hygiene, preop scrubs
Preop risk factors/comorbidities review
Operating Room
Changes in skin prep, sutures, scrubs and sponge washes
Use of Chlorhexidine
Improved Wound Classification documentation
Surgical Floors
IV Training
Wound Care Champions
Culture Wounds
PDSA Cycles – Best Practices Audits
OR Initiatives – Breast Surgeries
Jan 2008

Feb 2009

Preop Antibiotic
Administration

50%

76%

Antibiotic Timing

42%

100%

Normothermia

95%

100%

Warm Air/Blanket

17%

40%

Appropriate Hair
Removal

90%

100%
Preop Antibiotic Administration
*Looking at compliance rate
*Dates: Dec 1, 2009 to Jan 31, 2010 (n=176)
*Sources of Data: Chart
*Results:
(154/176) 87.5% of surgeries received preoperative antibiotics
(24/154) 16% given 1 min before incision time
(14/154) 9% given >1hr before incision time

No SSI
No Preop Antiobiotics
Preop Antibiotics
Given

P-value: .001

SSI

14 8
141 13

No SSI
No Preop Antiobiotics
Preop Antibiotics
Given within 1hr

SSI

24 12
131 9

P-value: .00008
Length of Stay Review
Colorectal Surgery
Length-of-Stay
Obs erved R a te:
41.82%
E xpected R a te:
26.48%
O/E R a tio: 1.58
S ta tus : Needs
Improvement
Length of Stay
Colorectal Surgeries

Acute Care

Emergent Count
Average LOS
Elective Count
Average LOS

Acute Care Count
Acute Care Average LOS

2005 2006 2007 2008 2009
35
57
53
41
26
24
21
21
17
16
77
68
80
91
37
15
9
10
10
10
112 125 133 132
63
18
15
14
12
13

Ave LOS in 2006 – Ave LOS in 2008 = Ave saved bed day/case in 2008
15 – 12 = 3
Saved bed day/case x # of Colorectal Sx in 2008 = Saved bed day in 2008

3 x 132 = 396 bed days saved in 2008
Examples of Data Integration
Graph 10: Overall SSI O/E Ratio
January 1, 2007 – December 31, 2007
95% Confidence Interval

FHA Appendectomies
(2005-2009)
2006

2008

2009

Total

Acute

65%

49%

52%

40%

52%

Perfed

Status:
Hospital A: Needs Improvement
Hospital B: Needs Improvement

2007

30%

48%

41%

33%

38%

5%

2%

7%

27%

10%

Lap

Annual Incidence  of Pneumonia from
Fiscal Year 2005 to 2009
Hospital A
5
Rate/100 Surgical Proced

Hospital B
4

2009 Postop SSI Summary

2

- NSQIP Average
1
0
2005

2006

2007
Fiscal Year

2008

2009

Site A

Site B

Site C

5.3%

3.4%

2.5%

Deep Incision SSI

3

Wound Occurrence
Superficial SSI

Hospital C

0.7%

1.0%

1.2%

Organ/Space SSI

5.1%

1.2%

0.6%
Replicate Published Studies
Time of Day Effects
Frequency of Surgical Start Time
12%
10%
8%
6%
4%

2 :3 - 3 0
2 0 2 :3

2 :3 - 1 0
0 0 2 :3

1 :3 - 9 0
8 0 1 :3

1 :3 - 7 0
6 0 1 :3

1 :3 - 5 0
4 0 1 :3

1 :3 - 3 0
2 0 1 :3

1 :3 - 1 0
0 0 1 :3

8 09 0
:3 - :3

6 07 0
:3 - :3

4 05 0
:3 - :3

2 03 0
:3 - :3

0%

0 :3 - :1 0
0 00 3

2%

Kelz, R., Tran, T., Hosokawa, P., Henderson, W., Paulson, C., Spitz, F., Hamilton, B., & Hall, B. (2009) Time-of-Day Effects on Surgical Outcomes in the Private Sector: A Retrospective Cohort
Study: Journal of the American College of Surgeons, 209-4, 434-445.
Time of Day Effects
Custom Fields
1. Anastomotic Leak
2. True Wait Time
3. True LOS
4. Readmission
5. DNR/Palliative Postop
Literature review
Standard definition
Data entry format
Source of data
Study duration – time dependent?
Trial
Revision of guidelines if needed
Appendectomies
Perfed vs Non-perfed
2006-2009 cases
n = 326
Perforated

Non-perforated

112 (34.36%)

214 (65.64%)

Wait Time
Door to Skin (Average)

5 hours

7 hours

Length of Stay

4 Days

2 Days

5.4%
3.4%
3.4%

3.3%
2.3%
0%

Distribution

Postop SSI
Superficial
Deep
Organ/Space
Patient Feedback
• 33% average return rate per cycle
• NSQIP clerk sorts and sends to Department Heads
• Challenging issues -forwarded to Client Relations Office
• Patient/Family meets with CRO and Chief of Surgery
Preop Albumin
Frequency of Preop Albumin Order for Emergent and Elective
Surgeries from 2006 to 2009
100%
80%
60%

Emergent
Elective

40%
20%
0%
2006

2007

2008

2009
Wait Time Reviews
Lap Chole
Average wait time: 78 hours

Appy

Wait Time

0 to 4hrs

5 to 8hrs

9 to 12hrs

>12hrs

Perfed

74(42%)

19(32%)

12(23%)

7(19%)

Nonperfed

104(58%)

41(68%)

40(77%)

29(81%)

Postop
Complications

13(7.3%)

5(8.3%)

5(9.6%)

7(19.4%)

Data shows increased postop complications as wait time increases
DNR Review

Examples of case reviews
Data Review for Planning and Decision Making
PACU
-LOS by procedure, LOS by type of anaesthesia (OR to PACU discharge)

Preadmission Clinic
Patient feedback – patient education needs
Risk assessments

OR Reorganization
RTO rates, length of surgery, time of surgery

Surgical Units
Discharge by day of the week – staffing
LOS and Outcomes

1South/Stepdown Unit
Admission criteria, LOS

Other hospital departments (housekeeping, dietary, pain service,
etc)
Patient Feedback
DVT/VTE Review
DVT/VTE Review
ID Score

Risk

1473

9

Highest Risk

1491

9

Highest Risk

3070

6

Highest Risk

3207

8

Highest Risk

3223

10

Highest Risk

4573

9

Highest Risk

5505

12

Highest Risk

5675

6

Highest Risk

5752

6

Highest Risk

1798

7

Highest Risk

2484

4

High Risk

3269

8

Highest Risk

3499

8

Highest Risk

3683

5

Highest Risk

3710

2

Moderate Risk

4155

8

Highest Risk

4892

4

High Risk

5325

7

Highest Risk

5528

5

Highest Risk

Jan 1, 2007 – Mar 31, 2010
• 19 DVT/PE Cases
• 3/19 (16%) RTO
• 2/19 (10.5%) Died
Cost Analysis
Cost of SSI after breast surgery: $ 4,091.00 USD ¹
Mastect omy SSI Tren d ov er Time
14%
12%
10%
8%
6%
4%
2%
0%
Q4
2007

Q1
2008

Q2
2008

Q3
2008

Q4
2008

Q1
2009

Q2
2009

Q3
2009

Q4
2009

Cost differential between inpt and outpt partial mastectomy: $ 2,800.00 CAD
Outpatient Partial Mastectomy
with Axillary Node Dissection (19302)
SMH

NSQIP

2008

17.9 %

78.9 %

2009

10.3 %

77.3 %

Reduction Rates between 2007 and 2009 for cases with at least 1 postoperative occurrence
Emergent: 27.40 % Elective: 9.05 %
Cost of postop UTI: $ 3,535 CAD (excluding physician fees)
Cost of Silver-coated catheter: $ 15.00
Averted UTI in 3 months: 18

¹Hospital-Associated Cost Due to Surgical Site Infection After Breast Surgery. Division of Infectious Disease, Washington University 2004
Canadian Institute for Health Information, The Cost of Hospital Stays: Why Costs Vary (Ottawa:CIHI 2008), does not include physician compensation, 2004-2005 data
Cost Analysis

Do the math!
$$$
July 2010 Semiannual Report
Structure and Process Evaluation
The Wisdom of Crowds
James Surowiecki

Why the Many Are Smarter Than the Few
diversity of opinion
independence
decentralization
aggregation
We vs Me
Who will speak up before I make a mistake?
flatten hierarchy
Does Team Have Patient Safety Focus?
checklist
How Do You “Stop The Line”?
CUS words
Is There Fear Of Retaliation?
need support from organization
Is Work Fun?
We are doing a great job!
Observations
Data is accepted as valid
No finger pointing developed
Change was viewed as necessary
Culture change underway

Flattened hierarchy
Safety and Quality articulated as goals
Learning “how to improve”
improve”
Patients notice change
It works!

More Related Content

What's hot

Ward procedures and preoperative care
Ward procedures and preoperative careWard procedures and preoperative care
Ward procedures and preoperative careAsok Kumar
 
Post operative-care,gynecology and obstetric
Post operative-care,gynecology and obstetricPost operative-care,gynecology and obstetric
Post operative-care,gynecology and obstetriczaid rasheed
 
Ambulatory surgery
Ambulatory surgeryAmbulatory surgery
Ambulatory surgeryManoj Vaidya
 
Perioperative care
Perioperative carePerioperative care
Perioperative carekokebey
 
Principles of preoperative and operative surgery
Principles of preoperative and operative surgeryPrinciples of preoperative and operative surgery
Principles of preoperative and operative surgeryMEEQAT HOSPITAL
 
Preoperative preparation for thoracic surgery
Preoperative preparation for thoracic surgeryPreoperative preparation for thoracic surgery
Preoperative preparation for thoracic surgerySaneesh P J
 
The person undergoing surgery
The person undergoing surgeryThe person undergoing surgery
The person undergoing surgerybluebird13
 
Preoperative managment
Preoperative managment Preoperative managment
Preoperative managment Bilal Mansoor
 
Perioperative Nursing (complete)
Perioperative Nursing (complete)Perioperative Nursing (complete)
Perioperative Nursing (complete)MarkFredderickAbejo
 
Care of a surgical patient
Care of a surgical patientCare of a surgical patient
Care of a surgical patientZeeshan Khan
 
Preoperative preparation of patients for surgery
Preoperative preparation of patients for surgeryPreoperative preparation of patients for surgery
Preoperative preparation of patients for surgeryErum Khateeb
 
perioperative nursing care
perioperative nursing careperioperative nursing care
perioperative nursing caretwiggypiggy
 
Ambulatory Surgery by Dr. Kenneth Dickie
Ambulatory Surgery by Dr. Kenneth DickieAmbulatory Surgery by Dr. Kenneth Dickie
Ambulatory Surgery by Dr. Kenneth DickieKenneth Dickie
 
general post operative care
general post operative caregeneral post operative care
general post operative careDr vimi jain
 

What's hot (20)

Ward procedures and preoperative care
Ward procedures and preoperative careWard procedures and preoperative care
Ward procedures and preoperative care
 
Post operative-care,gynecology and obstetric
Post operative-care,gynecology and obstetricPost operative-care,gynecology and obstetric
Post operative-care,gynecology and obstetric
 
Ambulatory surgery
Ambulatory surgeryAmbulatory surgery
Ambulatory surgery
 
Perioperative care
Perioperative carePerioperative care
Perioperative care
 
Day case for web
Day case for webDay case for web
Day case for web
 
Preoperative care
Preoperative carePreoperative care
Preoperative care
 
Pre operative care by umar tariq
Pre operative care by umar tariqPre operative care by umar tariq
Pre operative care by umar tariq
 
Principles of preoperative and operative surgery
Principles of preoperative and operative surgeryPrinciples of preoperative and operative surgery
Principles of preoperative and operative surgery
 
Preoperative preparation for thoracic surgery
Preoperative preparation for thoracic surgeryPreoperative preparation for thoracic surgery
Preoperative preparation for thoracic surgery
 
Day surgery
Day surgeryDay surgery
Day surgery
 
The person undergoing surgery
The person undergoing surgeryThe person undergoing surgery
The person undergoing surgery
 
Preoperative managment
Preoperative managment Preoperative managment
Preoperative managment
 
Perioperative Nursing (complete)
Perioperative Nursing (complete)Perioperative Nursing (complete)
Perioperative Nursing (complete)
 
Care of a surgical patient
Care of a surgical patientCare of a surgical patient
Care of a surgical patient
 
Preoperative preparation of patients for surgery
Preoperative preparation of patients for surgeryPreoperative preparation of patients for surgery
Preoperative preparation of patients for surgery
 
PERIOPERATIVE NURSING
PERIOPERATIVE NURSINGPERIOPERATIVE NURSING
PERIOPERATIVE NURSING
 
perioperative nursing care
perioperative nursing careperioperative nursing care
perioperative nursing care
 
Ambulatory Surgery by Dr. Kenneth Dickie
Ambulatory Surgery by Dr. Kenneth DickieAmbulatory Surgery by Dr. Kenneth Dickie
Ambulatory Surgery by Dr. Kenneth Dickie
 
general post operative care
general post operative caregeneral post operative care
general post operative care
 
Guidelines for-ambulatory-anesthesia-and-surgery
Guidelines for-ambulatory-anesthesia-and-surgeryGuidelines for-ambulatory-anesthesia-and-surgery
Guidelines for-ambulatory-anesthesia-and-surgery
 

Viewers also liked

Surgical Wound Classification
Surgical Wound ClassificationSurgical Wound Classification
Surgical Wound ClassificationDene W. Daugherty
 
Surgery tutorials for medical students
Surgery tutorials for medical studentsSurgery tutorials for medical students
Surgery tutorials for medical studentsBashir BnYunus
 
SURGICAL SITE INFECTIONS
SURGICAL SITE INFECTIONSSURGICAL SITE INFECTIONS
SURGICAL SITE INFECTIONSYogesh Patel
 
PATHOPHYSIOLOGY ANTERIOR CRUCIATE LIGAMENT INJURY
PATHOPHYSIOLOGY ANTERIOR CRUCIATE LIGAMENT INJURYPATHOPHYSIOLOGY ANTERIOR CRUCIATE LIGAMENT INJURY
PATHOPHYSIOLOGY ANTERIOR CRUCIATE LIGAMENT INJURYMa Wady
 
Wound: classification, healing and principle of management
Wound: classification, healing and principle of managementWound: classification, healing and principle of management
Wound: classification, healing and principle of managementKenna Urgessa
 
8. cesarean section
8. cesarean section8. cesarean section
8. cesarean sectionHishgeeubuns
 
Pathophysiology of wound healing
Pathophysiology of wound healingPathophysiology of wound healing
Pathophysiology of wound healingSaeed Al-Shomimi
 
wound healing PPT
wound healing PPTwound healing PPT
wound healing PPTorthoprince
 
Anterior Cruciate ligament Injury
Anterior Cruciate ligament Injury Anterior Cruciate ligament Injury
Anterior Cruciate ligament Injury Djair Garcia
 

Viewers also liked (12)

Surgical Wound Classification
Surgical Wound ClassificationSurgical Wound Classification
Surgical Wound Classification
 
Transmissible Infection Prevention - AORN Recommended Practices
Transmissible Infection Prevention - AORN Recommended PracticesTransmissible Infection Prevention - AORN Recommended Practices
Transmissible Infection Prevention - AORN Recommended Practices
 
Surgery tutorials for medical students
Surgery tutorials for medical studentsSurgery tutorials for medical students
Surgery tutorials for medical students
 
SURGICAL SITE INFECTIONS
SURGICAL SITE INFECTIONSSURGICAL SITE INFECTIONS
SURGICAL SITE INFECTIONS
 
PATHOPHYSIOLOGY ANTERIOR CRUCIATE LIGAMENT INJURY
PATHOPHYSIOLOGY ANTERIOR CRUCIATE LIGAMENT INJURYPATHOPHYSIOLOGY ANTERIOR CRUCIATE LIGAMENT INJURY
PATHOPHYSIOLOGY ANTERIOR CRUCIATE LIGAMENT INJURY
 
Wound: classification, healing and principle of management
Wound: classification, healing and principle of managementWound: classification, healing and principle of management
Wound: classification, healing and principle of management
 
8. cesarean section
8. cesarean section8. cesarean section
8. cesarean section
 
Wounds
WoundsWounds
Wounds
 
Wound healing
Wound healingWound healing
Wound healing
 
Pathophysiology of wound healing
Pathophysiology of wound healingPathophysiology of wound healing
Pathophysiology of wound healing
 
wound healing PPT
wound healing PPTwound healing PPT
wound healing PPT
 
Anterior Cruciate ligament Injury
Anterior Cruciate ligament Injury Anterior Cruciate ligament Injury
Anterior Cruciate ligament Injury
 

Similar to Surgeon Champion Call 2010 - Dr Peter Doris

03 manajemen risiko klinik (mrk)
03 manajemen risiko klinik (mrk)03 manajemen risiko klinik (mrk)
03 manajemen risiko klinik (mrk)Joni Iswanto
 
chris streather collaborative launch
chris streather collaborative launchchris streather collaborative launch
chris streather collaborative launchNHS Improving Quality
 
Crrt program -department final dr.osma elshahat
Crrt program -department final dr.osma elshahatCrrt program -department final dr.osma elshahat
Crrt program -department final dr.osma elshahatFarragBahbah
 
Postoperative pulmonary complications
Postoperative pulmonary complicationsPostoperative pulmonary complications
Postoperative pulmonary complicationsNHS
 
10 joyce neumann
10 joyce neumann10 joyce neumann
10 joyce neumannspa718
 
Evidence Based Practice: Assassination of Myths CAUTI (Catheter Associated Ur...
Evidence Based Practice: Assassination of Myths CAUTI (Catheter Associated Ur...Evidence Based Practice: Assassination of Myths CAUTI (Catheter Associated Ur...
Evidence Based Practice: Assassination of Myths CAUTI (Catheter Associated Ur...man0032
 
Quality Orientation.pptx
Quality Orientation.pptxQuality Orientation.pptx
Quality Orientation.pptxKimTurner50
 
A Urinary Tract Infection ( Uti )
A Urinary Tract Infection ( Uti )A Urinary Tract Infection ( Uti )
A Urinary Tract Infection ( Uti )Stephanie Williams
 
Introduction of the NZ Health IT Plan enables better gout management
Introduction of the NZ Health IT Plan enables better gout managementIntroduction of the NZ Health IT Plan enables better gout management
Introduction of the NZ Health IT Plan enables better gout managementHealth Informatics New Zealand
 
9. van anh vđ english
9. van anh vđ english9. van anh vđ english
9. van anh vđ englishvinhvd12
 
UK Urological Centre Cystectomy Service- an audit
UK Urological Centre Cystectomy Service- an auditUK Urological Centre Cystectomy Service- an audit
UK Urological Centre Cystectomy Service- an auditbnd861
 
Spanish Multi-Center Fast-Track Group - Protocol and Preliminary Results
Spanish Multi-Center Fast-Track Group - Protocol and Preliminary ResultsSpanish Multi-Center Fast-Track Group - Protocol and Preliminary Results
Spanish Multi-Center Fast-Track Group - Protocol and Preliminary Resultsfast.track
 
Safety in bariatric surgery.pptx
Safety in bariatric surgery.pptxSafety in bariatric surgery.pptx
Safety in bariatric surgery.pptxToshibAshok
 
Back to the Bedside: Internal Medicine Bedside Ultrasound Program
Back to the Bedside: Internal Medicine Bedside Ultrasound ProgramBack to the Bedside: Internal Medicine Bedside Ultrasound Program
Back to the Bedside: Internal Medicine Bedside Ultrasound ProgramAllina Health
 
Putting the Patient at the Heart of the Pathway
Putting the Patient at the Heart of the PathwayPutting the Patient at the Heart of the Pathway
Putting the Patient at the Heart of the PathwayNHSScotlandEvent
 

Similar to Surgeon Champion Call 2010 - Dr Peter Doris (20)

03 manajemen risiko klinik (mrk)
03 manajemen risiko klinik (mrk)03 manajemen risiko klinik (mrk)
03 manajemen risiko klinik (mrk)
 
POCT-1.pptx
POCT-1.pptxPOCT-1.pptx
POCT-1.pptx
 
chris streather collaborative launch
chris streather collaborative launchchris streather collaborative launch
chris streather collaborative launch
 
MLS13 QI Workshop
MLS13 QI WorkshopMLS13 QI Workshop
MLS13 QI Workshop
 
Crrt program -department final dr.osma elshahat
Crrt program -department final dr.osma elshahatCrrt program -department final dr.osma elshahat
Crrt program -department final dr.osma elshahat
 
Postoperative pulmonary complications
Postoperative pulmonary complicationsPostoperative pulmonary complications
Postoperative pulmonary complications
 
10 joyce neumann
10 joyce neumann10 joyce neumann
10 joyce neumann
 
Evidence Based Practice: Assassination of Myths CAUTI (Catheter Associated Ur...
Evidence Based Practice: Assassination of Myths CAUTI (Catheter Associated Ur...Evidence Based Practice: Assassination of Myths CAUTI (Catheter Associated Ur...
Evidence Based Practice: Assassination of Myths CAUTI (Catheter Associated Ur...
 
Quality Orientation.pptx
Quality Orientation.pptxQuality Orientation.pptx
Quality Orientation.pptx
 
A Urinary Tract Infection ( Uti )
A Urinary Tract Infection ( Uti )A Urinary Tract Infection ( Uti )
A Urinary Tract Infection ( Uti )
 
Introduction of the NZ Health IT Plan enables better gout management
Introduction of the NZ Health IT Plan enables better gout managementIntroduction of the NZ Health IT Plan enables better gout management
Introduction of the NZ Health IT Plan enables better gout management
 
9. van anh vđ english
9. van anh vđ english9. van anh vđ english
9. van anh vđ english
 
UK Urological Centre Cystectomy Service- an audit
UK Urological Centre Cystectomy Service- an auditUK Urological Centre Cystectomy Service- an audit
UK Urological Centre Cystectomy Service- an audit
 
Spanish Multi-Center Fast-Track Group - Protocol and Preliminary Results
Spanish Multi-Center Fast-Track Group - Protocol and Preliminary ResultsSpanish Multi-Center Fast-Track Group - Protocol and Preliminary Results
Spanish Multi-Center Fast-Track Group - Protocol and Preliminary Results
 
Fast Tracking Ambulatory Surgery Patients
Fast Tracking Ambulatory Surgery PatientsFast Tracking Ambulatory Surgery Patients
Fast Tracking Ambulatory Surgery Patients
 
Safe transitions in care
Safe transitions in careSafe transitions in care
Safe transitions in care
 
Canadian VTE Audit - Information Call
Canadian VTE Audit - Information CallCanadian VTE Audit - Information Call
Canadian VTE Audit - Information Call
 
Safety in bariatric surgery.pptx
Safety in bariatric surgery.pptxSafety in bariatric surgery.pptx
Safety in bariatric surgery.pptx
 
Back to the Bedside: Internal Medicine Bedside Ultrasound Program
Back to the Bedside: Internal Medicine Bedside Ultrasound ProgramBack to the Bedside: Internal Medicine Bedside Ultrasound Program
Back to the Bedside: Internal Medicine Bedside Ultrasound Program
 
Putting the Patient at the Heart of the Pathway
Putting the Patient at the Heart of the PathwayPutting the Patient at the Heart of the Pathway
Putting the Patient at the Heart of the Pathway
 

Recently uploaded

Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
Forensic Nursing powerpoint presentation
Forensic Nursing powerpoint presentationForensic Nursing powerpoint presentation
Forensic Nursing powerpoint presentationKavitha Krishnan
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
Cure of patients which terminally ill.pdf
Cure of patients which terminally ill.pdfCure of patients which terminally ill.pdf
Cure of patients which terminally ill.pdfrg0000009
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
A presentation on Thermal gravimetry analysis (TGA)
A presentation on Thermal gravimetry analysis (TGA)A presentation on Thermal gravimetry analysis (TGA)
A presentation on Thermal gravimetry analysis (TGA)1922Jaygohel
 

Recently uploaded (20)

Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Forensic Nursing powerpoint presentation
Forensic Nursing powerpoint presentationForensic Nursing powerpoint presentation
Forensic Nursing powerpoint presentation
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
Cure of patients which terminally ill.pdf
Cure of patients which terminally ill.pdfCure of patients which terminally ill.pdf
Cure of patients which terminally ill.pdf
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
A presentation on Thermal gravimetry analysis (TGA)
A presentation on Thermal gravimetry analysis (TGA)A presentation on Thermal gravimetry analysis (TGA)
A presentation on Thermal gravimetry analysis (TGA)
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 

Surgeon Champion Call 2010 - Dr Peter Doris

  • 1. Highlights of our Journey with ACS-NSQIP Surrey Memorial Hospital Surgeon Champion Call August 2010
  • 2. Data Quality Control QI in NSQIP Do we have to? How ? Who is responsible? What is acceptable? What`s the worst that could happen ?
  • 3. Data Quality Control SC and SCR meetings SCR and Surgical Program Director meetings Identify data errors Multiple postop occurrences Inpatient/Outpatients Subspecialty CPT Code DOB Wound Class
  • 4. 3.5 2.5 108.00 114.00 141.00 89.00 66.00 113.00 88.00 19.00 111.00 8.00 80.00 135.00 128.00 127.00 45.00 15.00 24.00 122.00 75.00 72.00 26.00 100.00 32.00 58.00 31.00 52.00 147.00 124.00 9.00 64.00 68.00 12.00 43.00 38.00 16.00 148.00 40.00 50.00 85.00 44.00 51.00 41.00 129.00 83.00 10.00 54.00 143.00 86.00 48.00 94.00 107.00 49.00 102.00 29.00 20.00 104.00 60.00 13.00 132.00 145.00 97.00 81.00 91.00 65.00 98.00 56.00 116.00 144.00 27.00 123.00 55.00 87.00 134.00 28.00 2.00 103.00 63.00 36.00 67.00 62.00 126.00 73.00 34.00 69.00 70.00 138.00 4.00 120.00 105.00 78.00 92.00 57.00 99.00 119.00 96.00 37.00 53.00 142.00 77.00 14.00 130.00 76.00 93.00 146.00 90.00 95.00 131.00 106.00 35.00 71.00 137.00 79.00 11.00 84.00 117.00 140.00 110.00 139.00 115.00 82.00 33.00 3.00 101.00 21.00 121.00 74.00 22.00 30.00 46.00 112.00 136.00 47.00 23.00 25.00 5.00 59.00 42.00 39.00 118.00 152.00 109.00 61.00 Overall Renal Complications Includes General and Vascular Surgery Cases 4 Outlier status: Needs improvement Good outcomes ACS-NSQIP Hospital ID Number Poor outcomes 3 Our Hospita 2 1.5 1 0.5 0
  • 8. Data Quality Control Date of Birth Errors MM/DD/YYYY vs DD/MM/YYYY Discharge Information Multiple admissions Multiple files on EMR for a single admission Wound Classification Errors 15% error per cycle
  • 10. Data Quality Control Missing Data Variables Then Now Future ASA 33% 2% Height 37% 24% Electronic and mandatory fields Weight 9% 6% OR Reports Available 2-3 months after OR 3-4 weeks Smoking History (ppy) 95% 30% Enhanced preop assessment Labs (Albumin) 79% 53% Links with external lab facilities 30-Day FF-up 92.1% 92.5% Translation Services Synoptic Reporting
  • 11. Data Quality Control Challenges CPT Codes *Discuss OR reports with Surgeon Champion *CPT Code mapping on Validation Worksheet ICD Codes *Surgeon’s offices/MOA Missing data *Revised nurses notes, assessment forms, anaesthesia record 30-day Follow-up *Telephone script for NSQIP clerks
  • 12. Database Design Excel spreadsheet with trends and graphs for each project Quarterly updates Formulas embedded in excel Pivot tables Access Database
  • 13. Data Reporting and Sharing Internal Surgical Committee Meetings OR Committee Meetings Council of Chiefs Chairs of Division Newsletters Intranet Update – Teams External FHA BCPSQC Provincial and National Other NSQIP participating sites
  • 14. Data Reporting and Sharing Education Learning Sessions Surgical Safety Collaborative Meetings In-service for frontline nurses Directors, executives and physicians New surgeons Posters
  • 19. Postoperative Pneumonia OE Raw Data – trend over time Rate/100 Surgical Procedures Incidence of Pneumonia from Jan 2007- Mar 2010 SMH NSQIP 6% 5% 4% 3% 2% 1% 0% Jan-Jun 2007 Jul-Dec 2007 Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009 Jul-Dec 2009 Jan-Mar 2010
  • 20. Postoperative Pneumonia More Data Emergency vs elective Pneumonia Occurrence Emergent vs Elective 10% 8% Rate SMH Emergent 6% NSQIP Emergent 4% p-value <.0001 SMH Elective NSQIP Elective 2% 0% Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009 Date Pneumonia RTO 2008 39 days 25 days 59 days 14 days 2008 31% 20% 2009 Mortality Elective 2009 LOS Emergent 23% 20% 2008 23% 10% 2009 15% 0%
  • 21. Postoperative Pneumonia More Data Emergent surgeries postop ventillation = 20/40 (50%) postop ventillation + positive culture = 19/40 (48%) Bugs were identified Candida Albicans excluded Pneum onia Occurrence Em ergent vs Elective 10% 8% SMH Electiv e 6% NSQIP Electiv e SMH Emergent 4% NSQIP Emergent 2% 0% Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009
  • 22. Postoperative Pneumonia Prevention Surrey Memorial Hospital Team Goal: Improvement Strategies *NSQIP data results July-Aug 2008: 3.4% Occurrence Rate Pn eum onia Occurrence Tren Over Tim d e Gen eral and Vascular Surgeries • Mobilization - Dangle post op day 0 if tolerated or HOB elevated - Increase activity as tolerated: Up to chair, walk X 1,2,3 etc. • Meticulous Hand Hygiene - Prevents transmission of micro-organisms between patients - Infection control involvement on team • Elevate Head of the Bed 30-40 Degrees - HOB elevation during transport, post op bed or stretcher - Rationale: Improves ventilation - Prevents aspiration of stomach & nasopharyngeal secretions Deep Breathing and Coughing Exercises - Rationale: Improves ventilation and prevents atelectasis - Assists with movement & expectoration of secretions • Chlorhexidine Gargle - Pre & post op oral decontamination - Evidence indicates may decrease pneumonia rates post surgery Education & Support - Patient and Family Education – Posters in rooms “Prevent Pneumonia” coaching & education pre-& post surgery for deep breathing & coughing - assisting with mobilization - encouraging self-care in recovery period post surgery - Staff Education – Huddles, emails, staff meetings, clinical update, new staff orientation Spot Check Pneumonia Prevention Action Team Chart#__ ____ ____ Date_ ____ ____ ___ COMPLETE In Patient’s Room: HOB elevated 30-40 degrees : Yes No N/A Patient mobilized day 0: Yes No N/A Patient dangled for 5 minutes X 1 Yes No N/A Or: HOB up 40 degrees for 5 minutes Yes No N/A Preadmission •Pre-op Education Pamphlet with Pneumonia Prevention Tips •Encouraging Partnership in Care •Changes in Standard Orders for Preoperative Oral Decontamination 6% 5% 4% % To decrease the incidence of pneumonia in postop bowel surgery patients by 50% using NSQIP by October 2009. SMH 3% 2% 1% 0% NSQIP 07 6-12/0 /0 6 0 1/07-06 /07 07/07 2/07 0 -1 1/08-0 6/08 07/08 -11/08 Dates Risk-Adjusted Pneumonia with Comparison to Other NSQIP Sites Observed Rate: 2.73% Expected Rate: 1.68% O/E Ratio: 1.62 Status: As Exp ected Spot Checks: Pre -Implementation October 2008: 50% HOB elevated February 2009: 71% HOB elevated Future Opportunities • Bowel Resection Carepaths • Changes in Preprinted Orders Reflecting Initiatives • Preadmission Education Pamphlets Revision Focusing on Self-Management • Spread and Integration of Bundles in Other SMH Units and FHA Sites TEAM MEMBERS Linda Coleman, PT Margaret Dyka-Gluzak, RN Linda Nelson, Educator Anne Edmond RN Irene Harder, RN Brenda Smith, RN Melissa Idle, Physio Raj Pandey, PT Angela Wilson RN Christine Donald, RN Angela Tecson, SCNR Sharon Parent, QI Donna Rolph, Manager 3 South Surgical Front Line Staff
  • 23. PDSA Cycles – Best Practices Audits Pneumonia Prevention Audit 100% HOB Elevated 60% DBC Teaching 40% DB&C Exercises Mobility Documentation 20% 0% Jun-09 Jul-09 Aug-09 Date of Audit Mobility Postop Day #0 Colorectals 100% 80% Rate Rate 80% HOB 60% Dangle 40% Walk 20% 0% Jun-09 Jul-09 Aug-09 Date of Audit Sep-09
  • 25. CAUTI Prevention Action Team Surrey Memorial Hospital Team Goal: Improvement Strategies As determined by frontline staff Initiation: reach 80% of staff 8 x 30 min education sessions (UTI Jeopardy) Picture 4 x 10 min unit based education (create awareness) Creation of prompts to stimulate awareness Sustainability Daily reminders with morning rounds Kardex Inserts Weekly spot checks led by frontline staff - continuing awareness for practice changes UTI Section to Initiative wall with current data of CAUTI infection rates on Unit CAUTI huddles – in presence of UTI infections U & I can eliminate UTI’s Actions; 2 person insertion & use smallest possible french Prewash perineal area & use chlore hexdine 2% swabs Secure safely (to unaffected side if limb trauma) No droopy Loops (ke ep between bladder and bag) Keep bag below the bladder and off the floor Label drainage container with name and date Rinse after every drain and discard q24hrs (0600) Always ask, why is this catheter in? Don’t forget... “2 Days Too Long” For everyday the catheter is in place, please assess, document; Reason why catheter is in place Has any follow up/ trial been done re: removal of catheter What is the plan for removal Is the patient exhibiting any signs and symptoms of UTI? If UTI suspected send C+S, and notify MD. After catheter removal,mobilize,hydrate patient & provide bowel care. If patient is unable to void follow these steps; consider the type of surgery, pt medical status and orders.… I/O catheter for volume >400cc, x 2 Obtaining Results then, if still unable to void Foley Catheter overnight and remove in AM If problem persists, consider urology consult 1. Silver Catheters: Insertion documented in chart, Kardex and tracking tool. Follow up audit to be done. 2. Practice Changes: weekly spot checks led by frontline staff. 3. CAUTI Rates: 5 patients with catheters (selected from weekly spot check) to be audited on weekly basis General and Vascular Surgeries Process Change UTI T rend Over Time 1.Trial of silver impregnated catheter In OR: insertion of silver catheters in bowel procedures On Unit: pre-operative insertion of silver catheters in the fractured hip population Practice Changes 1. Insertion 2 person insertion Pre-wash perineal area CHG 2% for aseptic urinary meatus cleaning Statlock securement to unaffected leg 2. Maintenance No droopy loops (dependant loops) Drainage bag between bladder and floor New drainage container q 24hrs Rinse drainage container after each drain 3. Removal “2 Days too Long” : Removing a urinary catheter at max post op day 2 at 0600 unless contraindicated If catheter remains in place: documenting reason for catheter and plan of care Encourage activities to promote voiding: Mobility, Hydration, Bowel care, Relaxation 4 3 % Decrease Catheter Associated Urinary Tract Infection rates 50% in the fractured hip population by June 2009 UTI Trend Over Time SMH 2 NSQIP 1 0 01 /06-06 /06 0 7/0 6-1 2/06 0 1/07 -0 6/07 07 /0 7-12 /0 7 01/0 8-06/0 8 0 7/08 -1 1/08 Dates Risk-Adjusted Overall Urinary Tract Infections with Comparison to Other NSQIP Sites Observed Rate: 2% Expected Rate: 1.34% O/E Ratio: 1.49 Status: As Exp ected Future Opportunities 1. Clinical decision making for Catheter reinsertion (i.e. bladder scan volume - what is acceptable? When does a catheter need to be inserted?) Align with HPA. 1. Continue with Silver Catheter trial and determine sustainability of long term use 1. Spread of CAUTI Prevention action items throughout the site. Initial spread to General Surgical Unit and the surgical program. Team Members : Jyotika Prasad Nen Graces Sharon Parent Jane Mann Felicia Laing Loretta Castelino Nicole Quilty Cindy Yazlovsky Linda Jennings Racheal Bertram Elizabeth Allan Angela Tecson 3S Surgical Orthopaedic Frontline Staff!!
  • 26. PDSA Cycle Orthopedic Ward – Silver Catheter Audit UTI TREND OVER TIME n 40 20 0 Apr-09 May-09 Jun-09 Apr-09 May-09 Jun-09 Ag Cath w/ UTI 0 0 0 Ag Cath 7 3 2 Reg Cath 18 13 6 Reg Cath w/ UTI 7 2 0 GS Ward – Catheter care audit Baseline Sept 2009 Nov 2009 Statlock on 100% 100% Plan for removal 50% 50% Droopy loops 100% 100% Bag above the bladder 0% 0% Bag on the floor 0% 0% Drainage container dated 0% 0% Catheter LOS (ave) 5 days 3.5 days
  • 27. Total Number of Cases Cases with SSI 3 0 Lymphadenectomy/Other 0 Immediate 2 Reconstruction 14 Mastectomy with 3 Modified, Radical 12 Mastectomy, Complete, 15 Mastectomy, Partial 16 Breast Mass Excision Gynecomastia 4 2 Mastectomy for Number of Cases Surgical Site Infection From bowels to breasts SSI Rates According to Type of Breast Surgery 14 14 10 10 8 6 0 2 1 0
  • 28. Surgical Site Infection Initiatives Safer Healthcare Now Preop antibiotic Warm air/blanket Appropriate hair removal Antibiotic timing/redosing Normothermia World Health Organization - Surgical Safety Checklist Briefings, Crew Resource Management Preadmission Patient Education – Hygiene, preop scrubs Preop risk factors/comorbidities review Operating Room Changes in skin prep, sutures, scrubs and sponge washes Use of Chlorhexidine Improved Wound Classification documentation Surgical Floors IV Training Wound Care Champions Culture Wounds
  • 29. PDSA Cycles – Best Practices Audits OR Initiatives – Breast Surgeries Jan 2008 Feb 2009 Preop Antibiotic Administration 50% 76% Antibiotic Timing 42% 100% Normothermia 95% 100% Warm Air/Blanket 17% 40% Appropriate Hair Removal 90% 100%
  • 30. Preop Antibiotic Administration *Looking at compliance rate *Dates: Dec 1, 2009 to Jan 31, 2010 (n=176) *Sources of Data: Chart *Results: (154/176) 87.5% of surgeries received preoperative antibiotics (24/154) 16% given 1 min before incision time (14/154) 9% given >1hr before incision time No SSI No Preop Antiobiotics Preop Antibiotics Given P-value: .001 SSI 14 8 141 13 No SSI No Preop Antiobiotics Preop Antibiotics Given within 1hr SSI 24 12 131 9 P-value: .00008
  • 31. Length of Stay Review Colorectal Surgery Length-of-Stay Obs erved R a te: 41.82% E xpected R a te: 26.48% O/E R a tio: 1.58 S ta tus : Needs Improvement
  • 32. Length of Stay Colorectal Surgeries Acute Care Emergent Count Average LOS Elective Count Average LOS Acute Care Count Acute Care Average LOS 2005 2006 2007 2008 2009 35 57 53 41 26 24 21 21 17 16 77 68 80 91 37 15 9 10 10 10 112 125 133 132 63 18 15 14 12 13 Ave LOS in 2006 – Ave LOS in 2008 = Ave saved bed day/case in 2008 15 – 12 = 3 Saved bed day/case x # of Colorectal Sx in 2008 = Saved bed day in 2008 3 x 132 = 396 bed days saved in 2008
  • 33. Examples of Data Integration Graph 10: Overall SSI O/E Ratio January 1, 2007 – December 31, 2007 95% Confidence Interval FHA Appendectomies (2005-2009) 2006 2008 2009 Total Acute 65% 49% 52% 40% 52% Perfed Status: Hospital A: Needs Improvement Hospital B: Needs Improvement 2007 30% 48% 41% 33% 38% 5% 2% 7% 27% 10% Lap Annual Incidence  of Pneumonia from Fiscal Year 2005 to 2009 Hospital A 5 Rate/100 Surgical Proced Hospital B 4 2009 Postop SSI Summary 2 - NSQIP Average 1 0 2005 2006 2007 Fiscal Year 2008 2009 Site A Site B Site C 5.3% 3.4% 2.5% Deep Incision SSI 3 Wound Occurrence Superficial SSI Hospital C 0.7% 1.0% 1.2% Organ/Space SSI 5.1% 1.2% 0.6%
  • 34. Replicate Published Studies Time of Day Effects Frequency of Surgical Start Time 12% 10% 8% 6% 4% 2 :3 - 3 0 2 0 2 :3 2 :3 - 1 0 0 0 2 :3 1 :3 - 9 0 8 0 1 :3 1 :3 - 7 0 6 0 1 :3 1 :3 - 5 0 4 0 1 :3 1 :3 - 3 0 2 0 1 :3 1 :3 - 1 0 0 0 1 :3 8 09 0 :3 - :3 6 07 0 :3 - :3 4 05 0 :3 - :3 2 03 0 :3 - :3 0% 0 :3 - :1 0 0 00 3 2% Kelz, R., Tran, T., Hosokawa, P., Henderson, W., Paulson, C., Spitz, F., Hamilton, B., & Hall, B. (2009) Time-of-Day Effects on Surgical Outcomes in the Private Sector: A Retrospective Cohort Study: Journal of the American College of Surgeons, 209-4, 434-445.
  • 35. Time of Day Effects
  • 36. Custom Fields 1. Anastomotic Leak 2. True Wait Time 3. True LOS 4. Readmission 5. DNR/Palliative Postop Literature review Standard definition Data entry format Source of data Study duration – time dependent? Trial Revision of guidelines if needed
  • 37. Appendectomies Perfed vs Non-perfed 2006-2009 cases n = 326 Perforated Non-perforated 112 (34.36%) 214 (65.64%) Wait Time Door to Skin (Average) 5 hours 7 hours Length of Stay 4 Days 2 Days 5.4% 3.4% 3.4% 3.3% 2.3% 0% Distribution Postop SSI Superficial Deep Organ/Space
  • 38. Patient Feedback • 33% average return rate per cycle • NSQIP clerk sorts and sends to Department Heads • Challenging issues -forwarded to Client Relations Office • Patient/Family meets with CRO and Chief of Surgery
  • 39. Preop Albumin Frequency of Preop Albumin Order for Emergent and Elective Surgeries from 2006 to 2009 100% 80% 60% Emergent Elective 40% 20% 0% 2006 2007 2008 2009
  • 40. Wait Time Reviews Lap Chole Average wait time: 78 hours Appy Wait Time 0 to 4hrs 5 to 8hrs 9 to 12hrs >12hrs Perfed 74(42%) 19(32%) 12(23%) 7(19%) Nonperfed 104(58%) 41(68%) 40(77%) 29(81%) Postop Complications 13(7.3%) 5(8.3%) 5(9.6%) 7(19.4%) Data shows increased postop complications as wait time increases
  • 41. DNR Review Examples of case reviews
  • 42. Data Review for Planning and Decision Making PACU -LOS by procedure, LOS by type of anaesthesia (OR to PACU discharge) Preadmission Clinic Patient feedback – patient education needs Risk assessments OR Reorganization RTO rates, length of surgery, time of surgery Surgical Units Discharge by day of the week – staffing LOS and Outcomes 1South/Stepdown Unit Admission criteria, LOS Other hospital departments (housekeeping, dietary, pain service, etc) Patient Feedback
  • 44. DVT/VTE Review ID Score Risk 1473 9 Highest Risk 1491 9 Highest Risk 3070 6 Highest Risk 3207 8 Highest Risk 3223 10 Highest Risk 4573 9 Highest Risk 5505 12 Highest Risk 5675 6 Highest Risk 5752 6 Highest Risk 1798 7 Highest Risk 2484 4 High Risk 3269 8 Highest Risk 3499 8 Highest Risk 3683 5 Highest Risk 3710 2 Moderate Risk 4155 8 Highest Risk 4892 4 High Risk 5325 7 Highest Risk 5528 5 Highest Risk Jan 1, 2007 – Mar 31, 2010 • 19 DVT/PE Cases • 3/19 (16%) RTO • 2/19 (10.5%) Died
  • 45. Cost Analysis Cost of SSI after breast surgery: $ 4,091.00 USD ¹ Mastect omy SSI Tren d ov er Time 14% 12% 10% 8% 6% 4% 2% 0% Q4 2007 Q1 2008 Q2 2008 Q3 2008 Q4 2008 Q1 2009 Q2 2009 Q3 2009 Q4 2009 Cost differential between inpt and outpt partial mastectomy: $ 2,800.00 CAD Outpatient Partial Mastectomy with Axillary Node Dissection (19302) SMH NSQIP 2008 17.9 % 78.9 % 2009 10.3 % 77.3 % Reduction Rates between 2007 and 2009 for cases with at least 1 postoperative occurrence Emergent: 27.40 % Elective: 9.05 % Cost of postop UTI: $ 3,535 CAD (excluding physician fees) Cost of Silver-coated catheter: $ 15.00 Averted UTI in 3 months: 18 ¹Hospital-Associated Cost Due to Surgical Site Infection After Breast Surgery. Division of Infectious Disease, Washington University 2004 Canadian Institute for Health Information, The Cost of Hospital Stays: Why Costs Vary (Ottawa:CIHI 2008), does not include physician compensation, 2004-2005 data
  • 46. Cost Analysis Do the math! $$$
  • 48. Structure and Process Evaluation
  • 49. The Wisdom of Crowds James Surowiecki Why the Many Are Smarter Than the Few diversity of opinion independence decentralization aggregation
  • 50. We vs Me Who will speak up before I make a mistake? flatten hierarchy Does Team Have Patient Safety Focus? checklist How Do You “Stop The Line”? CUS words Is There Fear Of Retaliation? need support from organization Is Work Fun? We are doing a great job!
  • 51. Observations Data is accepted as valid No finger pointing developed Change was viewed as necessary Culture change underway Flattened hierarchy Safety and Quality articulated as goals Learning “how to improve” improve” Patients notice change It works!