Surgical Care Improvement Project QSource Hospital Quality Improvement Team Spring 2008 THA Patient Safety Center “Reducing Hospital Acquired Infections” Collaborative Regional Networking Workshops Knoxville / Nashville / Memphis

“The right care for every person, every time.” CMS Vision Statement For the National Healthcare Quality Improvement Program

“The Right Care”  Safe  Timely  Effective  Efficient  Equitable  Patient-centered Institute of Medicine

“Every Person, Every Time”  Medicare Conditions of Participation (CoP) for Hospitals  “Medical error” includes “omissions”  Performance improvement requirements increased  Evidence-based medicine is key  Reliability – all aspects of care for which the patient is eligible

The Surgical Care Improvement Project Ongoing Gaps in Performance Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality

Why focus on surgical quality Patients who experience a postoperative complication have dramatically increased hospital length of stay, hospital costs, and mortality –On average, the length of stay for patients who have a postoperative complication is 3 to 11 days longer –Odds of dying within 60 days increases 3.4-fold in patients with a complication* *Silber JH, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43:

Surgical Care Improvement Project Hospital Voluntary Self-Reporting, Qtr. 2, 2007 Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of Care TM methodology (

Surgical Care Improvement Project Hospital Voluntary Self-Reporting, Qtr. 2, 2007

Ongoing Gaps in Performance Tennessee, Qtr. 2, 2007 “Low- and High- Performers” represent the average performance of those hospitals caring for 10% of the Tennessee surgical population.

Ongoing Gaps in Performance Tennessee, Qtr. 2, 2007 “Low- and High- Performers” represent the average performance of those hospitals caring for 10% of the Tennessee surgical population.

Data Source: QIO Warehouse TN Hospital-Generated Data – 2004 Discharges

Integrating the Johns Hopkins “4Es” Model with the PDSA Cycle and the IHI “Model for Improvement”

Unit-Based, Small-Scale Tests of Change Ideas  Learn how to adapt the change idea to the conditions in your local environment  Document how much improvement can be expected from the change  Minimize resistance when implementing the change on a wider scale

Monthly Project Reporting Expectations  Team Check-up Tool  Quality Measure Rates

Helpful Interventions  Leadership engagement  Front line staff involvement  Physician Champions  Peer to Peer discussions of the medical evidence  Individual, comparative data feedback  Concurrent care management  Cross-functional multidisciplinary teams  Lessons learned from the aviation industry

Peg Game Exercise

The Peg Game

PDSA for the “PEG Exercise”

Next Steps / Evaluation

 Aim Statement - Leadership  Team Formation  Engage and Educate  Select and test change ideas  Display the Team’s story / journey  Next Regional Networking Workshops – August 2008

Thank you! Judy Weddle Lesley Hays This presentation and related materials were prepared by QSource, the Medicare Quality Improvement Organization for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department for Health and Human Services. Contents do not necessarily reflect CMS policy.