QPIINVESTIGATORS

QPIINVESTIGATORS

MissionTo provide exceptional care to every patient every day with a spirit of warmth, friendliness and personal pride.

Values - I.C.A.R.E.• Integrity • Compassion • Accountability • Respect • Excellence

VisionExceptional Care, Customer Loyalty, Financial Strength

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Texas Award for Performance Excellence

Same criteria and process as the Malcolm Baldridge National Quality Award! Awarded to organizations that serve as role models for quality, customer satisfaction, and performance excellence in Texas

Texas Health Care Quality Improvement Award

Awarded by TMF® Health Quality Institute, the Medicare Quality Improvement Organization for Texas

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Interviewee:

Shannon Kane-Reinhardt RN, BSN, Quality Manager

Interviewers:

• Lombe Chitundu• Jean Cusick• Yolanda Johnson• Vicki McGinnis• Sharon Royall-Murphy

Interview Date: March 30, 2010

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Step 5: Perform Ongoing Monitoring

Step 4: Identify Improvement Opportunity

Step 3: Analyze and Compare Data

Step 2: Measure Performance

Step 1: Identify Performance Measures

5 Steps in an Organizational PI Model

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Core Measures SCIP

Antibiotic Received Within One Hour Prior to Surgical Incision (SCIP-Inf-1a)

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SCIP-Inf-1a

SurgicalPatients

Reduced risk of post-operative

infections

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Hospital Areas Studied

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Data Collection Process

• Name of surgeon• Date of surgery• Surgical procedure

(ie. CABG, Cardiac)

OR ModuleChart

• Antibiotic Administration Route

• Antibiotic Name • Antibiotic Received

AnesthesiaRecord

• Sampling of Surgical Patients

ConfidentialSpreadsheet

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Measurement Ratio

Number of surgical patients with antibiotics initiated within one hour prior to surgical incision

All selected surgical patients with no evidence of prior infection.

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Data added to spreadsheet:

Name of surgeonCase identifierDate of surgeryReason for outlier

(why not started on time)

Responsibility (who started antibiotic)

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OperatingRoom

Timeout Checklists

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Benchmark- 90th Percentile Q1 09 Projected Q2 09 Projected Q3 09 Projected Q4 09 Projected Q1 10

SCIP 97.77% 98.27% 98.27% 98.58% 98.23%

Measure 1 Q 2009 2 Q 2009 3 Q 2009 4 Q 2009 1Q 2010

SCIP Composite Measure** 97.71% 99.12% 99.14% 97.79% 98.84%

Prophylactic antibiotic received w /in 1 hr prior to incisionP^93.9% 98.6% 98.6% 97.5% 100.0%

CABG 100.0% 100.0% 100.0% 100.0% 100.0%

Cardiac surgery 50.0% 100.0% 100.0% 100.0% 0.0%

Hip arthroplasty 92.9% 100.0% 94.4% 100.0% 100.0%

Knee arthroplasty 96.3% 100.0% 100.0% 96.2% (25/26) 100.0%

Colon surgery 85.7% 83.3% 100.0% 88.9% (8/9) 100.0%

Hysterectomy 93.3% 100.0% 100.0% 100.0% 100.0%

Vascular surgery 100.0% 100.0% 100.0% 0.0%

Prophylactic antibiotic selection for surgical patientsP^98.8% 100.0% 98.6% 96.3% 97.3%

CABG 100.0% 100.0% 100.0% 100.0% 100.0%

Cardiac surgery 100.0% 100.0% 100.0% 100.0% 0.0%

Hip arthroplasty 100.0% 100.0% 100.0% 100.0% 100.0%

Knee arthroplasty 100.0% 100.0% 100.0% 100.0% 100.0%

Colon surgery 100.0% 100.0% 100.0% 100.0% 100.0%

Hysterectomy 93.3% 100.0% 92.9% 88.9% (24/27) 86.7% (13/15)

Vascular surgery 100.0% 100.0% 100.0% 0.0%

RRMC Core Measures DashboardSurgical Care Improvement Project (SCIP)

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The Report Card

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External Performance Reporting

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SCIP Champions

Pharmacy

OR ServicesPre-op, OR,

PACU

Ortho Anesthesia

Quality

Information Services

(IS)

Multidisciplinary PI Team

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Board of

Director

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CMO

Quality Executive

Committee LeadershipTeam

Dashboard

(Report Card)

Organization-wide PI Communications

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PI Cycle

Computer SystemChanges

OR Charting ModuleRollout

PI ProcessIssues

(Outliers)

Process change(s) in other areas

Factors influencing ongoing improvement efforts

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Core Measure Set – SCIP ( 289/296= 97.64%; Benchmark 98.23%)Missed Element Reason for Miss ActionAntibiotic Selection (40/42=95.24%)

Outlier 1 Hysterectomy. Patient was given Cleocin and Gentamycin antibiotics. No documentation of an beta lactam allergy. Per CMS guidelines these two antibiotics are recommended only if patient has a beta lactam allergy.

1)Pharmacy and Quality review of preoperative antibiotics. 2) Outlier provider letters

Outlier 2 Hysterectomy. Patient was given Cleocin and Gentamycin antibiotics. No documentation of an beta lactam allergy but patient did have an allergy to erythromycin. Per CMS guidelines these two antibiotics are recommended only if patient has a beta lactam allergy.

VTE Ordered (38/40=95%) and VTE Received (37/40=92.5%)

Outlier 4 and 5 Exploratory Laparotomy. No pharmacological VTE prophylaxis was ordered within 24 hours after surgery end-time. There is no documentation of a contraindication to VTE prophylaxis. Hospitalist documented "? Lovenox" in the progress notes and wrote an order for Lovenox "if okay with surgeon". Surgeon ordered the Lovenox outside of the 24 hour timeframe. Per CMS guidelines VTE prophylaxis needs to be ordered and given within 24 hours of surgery.

Major case, new physician, More focus on time sensitive measures and major cases.

Outlier 6 and 7 Exploratory Laparotomy. Lovenox was not ordered on patient during hospitalization. Surgeon queried. No contraindication to pharmaceutical VTE noted.

Major case, not followed timely by concurrent review. Surgeon willing to help champion a General Surgery order set.

Outlier 8 Exploratory Laparotomy. Lovenox was ordered on POD 1 as a "now" order. Nursing had approximately 1 hour to administer within the SCIP 24 hour window. Patient did not received the Lovenox until approx 6 hours later.

Same Surgeon as outlier 6 and 7. Nursing outlier review.

Executive Summary of Action Plans

QPIINVESTIGATORS

The hospital indicated that the data submitted for this measure were based on a sample of cases.

HCAHPS Customer Satisfaction Survey

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Microsoft Office Labs. StickySorter. 3 August 2009. 17 February 2010 <http://www.officelabs.com/projects/stickysorter/Pages/default.aspx>.

St David's Round Rock Medical Center. About Us. 10 April 2010 <http://stdavids.com/about-us>.

The Joint Commission. Performance Measure Initiatives. 2 April 2010. 10 April 2010 <http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm>.

The Joint Commission. Quality Data Download. 5 April 2010. 10 April 2010 <http://www.qualitycheck.org/consumer/searchresults.aspx?nm=st+davids&ddstatelist=TX&st_nm=TEXAS&st=TX>.

US Department of Health and Human Services. Hospital Compare. 18 March 2010. 10 April 2010 <www.hospitalcompare.hhs.gov >.