1. Building NSQIP Across FH Donna Rolph Nov 2012

2. Background on FH FH has 12 hospitals extending from Burnaby to White Rock to Boston Bar We serve >1.5 million residents We have >26,000 employees

3. Background on FH in NSQIP Three sites were early members: Surrey Memorial Hospital Royal Columbian Hospital Burnaby Hospital

4. June 2011….. Very dedicated SC taking NSQIP to whomever would listen Very dedicated and qualified staff Staff working looooong hours to get data in before lock-out Silos Spread of NSQIP very slow Very dedicated SC taking NSQIP to whomever would listen Very dedicated and qualified staff Staff working looooong hours to get data in before lock-out Silos Spread of NSQIP very slow

5. FH NSQIP Focus in 2011-2012 Establishing organizational structures Staffing & Compensation Surgical Clinical Reviewers Surgeon Champions NSQIP Office Clerks NSQIP Quality Improvement Consultants Setting up offices at each site Establishing organizational structures Staffing & Compensation Surgical Clinical Reviewers Surgeon Champions NSQIP Office Clerks NSQIP Quality Improvement Consultants Setting up offices at each site

6. FHA NSQIP ORGANIZATIONAL CHART Donna Rolph Manager Dr. Peter Doris Surgeon Champion Dr Sharon Ong Surgeon CHampion SMH Pawan Sidhar SCR 2 Parm Panesar SCR 1 Jas Dhami NSQIP Clerk Dr. Peter Blair Surgeon Champion RCH Vacant SCR2 Leslie Jones SCR 1 Bonnie Gallop NSQIP Clerk Heather Symons SCR Relief Heather Bolecz SCR 1 Maureen Shaw Casual SCR Vacant 0.8 Relief SCR Dr. JohnNoel Mahy Surgeon Champion BH Darlene Jager SCR 2 Melody Pan SCR 1 Sarah Taylor- Claydon NSQIP Clerk Lucy Maradiaga Casual clerk Dr. Mitra Maharaj Surgeon Champion LMH Lila Gottenbos SCR 2 Denise Sherban SCR 1 Angela Oliver NSQIP Clerk Susann Camus QI consultant Dr. Hwang Surgeon Champion PAH Laura Holmes SCR 2 Vacant SCR 1 Rita Bedwell NSQIP Clerk Mike Arget QI Consultant Dr. Dalbhir Jangra Surgeon Champion ARH Bryan Wilkinson SCR 2 Ericka Gergely SCR 1 Angela Oliver NSQIP Clerk Dr. D Konkin Surgeon Champion ERH Kim Beaudry SCR 2 Betty Allan SCR 1 Bonnie Gallop NSQIP Clerk Dr. Daniel Robibo Surgeon Champion DH Ronelle Gutierrez SCR 2 Darlene Spence SCR 1 Rita Bedwell NSQIP Clerk Dr. Marni Heed Surgeon Champion RM Heather Hunter SCR 2 Lea Klein SCR 1 Kali Forstbauer NSQIP Clerk Dr. Sean Brown Surgeon Champion JPOCSC Angela Tecson SCR 2 Vacant SCR 1 Jas Dhami NSQIP Clerk Dr. Christo Wiggins Surgeon Champion CGH TBA SCR 2 NO SCR 1 Kali Forstbauer NSQIP CLerk Sue Malhi Program Clerk

7. Team Building 3-day workshop to formulate mission, vision, values Strengthening Individual competencies Establishment of teams

8. FH NSQIP Focus in 2012-2013 Using data to set goals at each site Analyzing the data Getting the word out about NSQIP internally Sending Surgical Clinical Reviewers and frontline staff to the Quality Academy Sustainability of goals Using data to set goals at each site Analyzing the data Getting the word out about NSQIP internally Sending Surgical Clinical Reviewers and frontline staff to the Quality Academy Sustainability of goals

9. FH NSQIP Focus in 2012-2013 Action teams up and running at all sites Bulletin boards on every surgical unit with data and updates of team work Reducing postsurgical complications Getting the word out beyond FH Demonstrating a return on investment Action teams up and running at all sites Bulletin boards on every surgical unit with data and updates of team work Reducing postsurgical complications Getting the word out beyond FH Demonstrating a return on investment

10. Where are we at? NSQIP at 10 of 11 sites New sites spreading what NSQIP is ERH/RM/JP; ERH/CGH have had open houses Teams at BH, LMH, ARH, SMH, PAH, DH CUSP at RCH with John Hopkins Five of our teams are presenting here (BH-pneumonia px; PAH- Wound classification; LMH-UTI; SMH-UTI; PAH-CAUTI NSQIP at 10 of 11 sites New sites spreading what NSQIP is ERH/RM/JP; ERH/CGH have had open houses Teams at BH, LMH, ARH, SMH, PAH, DH CUSP at RCH with John Hopkins Five of our teams are presenting here (BH-pneumonia px; PAH- Wound classification; LMH-UTI; SMH-UTI; PAH-CAUTI

11. Where are we at? Research at 2 sites. LOI accepted proposals being written Articles for publication—2 planned for Dec/12 NSQIP invited to provincial PACU workshop (Ronelle and Kim) represented us Standardizing of processes, report template, clerk orientation manual (draft) Research at 2 sites. LOI accepted proposals being written Articles for publication—2 planned for Dec/12 NSQIP invited to provincial PACU workshop (Ronelle and Kim) represented us Standardizing of processes, report template, clerk orientation manual (draft)

12. Sept 27 Workshop for region 140 attended

13. Where are we at? We have working teams: Orientation/Education; Technology, Research/Publishing, Communications/Marketing, Business Management, NSQIP Resource Team Agenda item at: QI Rounds; Surgical Operations (Directors and Managers); QI Improvement (Dr Committee); Executive Report monthly; Infection control monthly meeting We have working teams: Orientation/Education; Technology, Research/Publishing, Communications/Marketing, Business Management, NSQIP Resource Team Agenda item at: QI Rounds; Surgical Operations (Directors and Managers); QI Improvement (Dr Committee); Executive Report monthly; Infection control monthly meeting

14. FH NSQIP: Mission: Connecting Healthcare providers with quality data to improve outcomes for surgical patients Vision: FH NSQIP leading the way in providing optimum patient outcomes Mission: Connecting Healthcare providers with quality data to improve outcomes for surgical patients Vision: FH NSQIP leading the way in providing optimum patient outcomes