1. Quality Improvement Committee Report
Surgical Services
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 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
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

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