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 Surgical Care Improvement Program (SCIP) Keystone Surgery Collaborative Goals Infection Control Patient Education Customer Service

SCIP Dashboard

Surgical Care Improvement Program (SCIP)

Keystone Quality Initiatives

Keystone

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 Pre-operative   Surgical Site Cleansing Instructions 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). IC statistics 03/2012

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.

Quality Customer Service

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

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

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

Thank you