Engaging your Surgeon Champion and Hospital Staff

Size: px
Start display at page:

Download "Engaging your Surgeon Champion and Hospital Staff"

Transcription

1 Engaging your Surgeon Champion and Hospital Staff Debbie Liebrecht, RN, CPHQ SCR (individual no team) Children s Hospital Colorado NSQIP-Pediatric Debra.Liebrecht@childrenscolorado.org

2 Disclosures Nothing to disclose

3 Children s Hospital Colorado was established in 1908 A new 444 bed children s hospital was built in 2007 US News & World Report has ranked us among best children s hospitals for over 20 years

4 4 th busiest pediatric surgical program in U.S pediatric surgery experts, each with a passion for quality, each with a personal vision for what quality is

5 What is the REAL VALUE of NSQIP? Clinical chart review by trained SCRs NSQIP clinical outcomes data o Are far more informative and comprehensive than administrative and claims data o Show what is happening to the patient in the hospital and through 30 days NSQIP provides risk adjusted Semi-Annual Reports which are actionable, as well as occurrence, reoperation and readmission reports NSQIP provides Participant Use File (PUF) reports which provide de-identified raw data, which are commonly used for publication

6 Getting everyone on the same page, or at least looking at the same book Engaging surgeons Record and report the evidence for occurrences Copy and paste surgeon s own words and details from progress notes in chart to Comments section of Occurrences Run reports containing occurrences with comments from operating surgeon/operating team Provide copies of Chapter 4 Occurrence Definitions to surgical team Offer to be available for questions

7 Demonstrate value of NSQIP data by including Hospital Staff A. Identify departments and subspecialties working on quality improvement issues Quality and Safety Department/Administrators Epidemiology/Infection Control Surgical Site Infection Task Forces Specialties, subspecialties, residents looking for IRB approved research projects

8 Demonstrate value of NSQIP reports for measuring Quality Improvement B. Engage identified partners Set up monthly meetings to review a variety of reports o Prepare to discuss areas of interest to recipients Readmissions/Reoperations for Q&S/Administrators SSI for Epidemiology/Infection Control Unplanned reintubations for ENT/Pulmonary/Anesthesia

9 Demonstrate value for patient safety projects & potential cost savings C. Increase visibility of NSQIP Give presentations to more targeted groups o Quality & Safety quarterly meetings o Hospital Councils o Surgical High Risk Task Forces o Quality Improvement Project staff o Perioperative Services Operations Team o Hospital Acquired Infection Prevention Team

10 Demonstrate value of what you do with steadfast perseverance D. Work with groups to identify Process Improvement/Quality Improvement topics and generate projects Set up the meetings, reserve the meeting rooms Send reminders, seek confirmation Set and send out the agenda Offer to work one-on-one with group members to nail down details Pilot test the project, revise original project as needed Create evaluation tool to track progress Repeat for next project

11 Demonstrate value of what can be done by building a shared data network E. Collaborate with other reporting entities who may have different data Create a shared database for occurrence reporting o Infection Control SSIs compared w/ NSQIP SSIs NSQIP full chart review vs. IC surveillance of positive cultures NSQIP data always reveal more SSIs compared to IC surveillance using NHSN protocol

12 Celebrate Success Prepare for Challenges Include all successful projects in your performance review Advocate for staff to assist in successful PI/QI projects Persist even in the face of flagging enthusiasm Acknowledge barriers and work toward solutions Renew commitment to invigorate a planning and development process in order to achieve the goal of enhanced engagement Thank you to my colleagues and fellow SCRs Dave Lunney, Robert Beck, & Ann Douglas for their help in preparing this presentation I d like to acknowledge Bonnie Anderson who was the de-facto lead SCR who helped make NSQIP- Pediatric what it is today

EHR Enablement for Data Capture

EHR Enablement for Data Capture EHR Enablement for Data Capture Baylor Scott & White (15 min) Bonnie Hodges, RN University of Chicago Medicine(15 min) Susan M. Sullivan, RHIA, CPHQ Kaiser Permanente (15 min) Molly P. Clopp, RN Tammy

More information

ACS NSQIP Pediatric Participant Use Data File (PUF)

ACS NSQIP Pediatric Participant Use Data File (PUF) ACS NSQIP Pediatric Participant Use Data File (PUF) Christine L. Sullivan, MBA, MS Continuous Quality Improvement, Division of Research and Optimal Patient Care American College of Surgeons July 22, 2017

More information

ACS NSQIP Tools for Success. Pre-Conference Session July 25, 2015

ACS NSQIP Tools for Success. Pre-Conference Session July 25, 2015 ACS NSQIP Tools for Success Pre-Conference Session July 25, 2015 No disclosures Disclosure Slide Collect the Data Continuous Quality Improvement Implement QI ACS NSQIP Analyze the Data Utilize Tools Current

More information

LANCASTER GENERAL HEALTH

LANCASTER GENERAL HEALTH Lori Abel RN, M.Ed. NO DISCLOSURES Penn Medicine Lancaster General Health LANCASTER GENERAL HEALTH Integrated Health System serving Lancaster Pennsylvania with a regional population ~1 million 631 licensed

More information

The Basics of the Quality In-Training Initiative (QITI)

The Basics of the Quality In-Training Initiative (QITI) The Basics of the Quality In-Training Initiative (QITI) Caroline Reinke, MD MSHP Assistant Professor, Carolinas HealthCare System Best Practices in Quality and Resident Education P01 Friday July 21 st,

More information

An Interactive Panel Session for the Novice ACS NSQIP SCR. Sunday, July 23, :30 p.m. 2:00 p.m.

An Interactive Panel Session for the Novice ACS NSQIP SCR. Sunday, July 23, :30 p.m. 2:00 p.m. An Interactive Panel Session for the Novice ACS NSQIP SCR Sunday, July 23, 2017 12:30 p.m. 2:00 p.m. Disclosure: None The author(s) and presenter(s) have no relevant financial relationships with commercial

More information

Enhanced Recovery After Surgery (ERAS) for Elective Colon Resection Surgery at Vancouver General Hospital. What is Possible?

Enhanced Recovery After Surgery (ERAS) for Elective Colon Resection Surgery at Vancouver General Hospital. What is Possible? Enhanced Recovery After Surgery (ERAS) for Elective Colon Resection Surgery at Vancouver General Hospital What is Possible? BC Provincial Collaborative November 25, 2014 Disclosure Statement I do not have

More information

Our SAR Looks Great, Now What? ACS NSQIP Pediatric

Our SAR Looks Great, Now What? ACS NSQIP Pediatric Our SAR Looks Great, Now What? ACS NSQIP Pediatric Jacqueline Saito, MD, MSCI, FACS St. Louis Children s Hospital Surgeon Champion ACS Children s Surgery Data Committee Vice Chair Disclosures I have no

More information

What s next? Joint Commission Center for Transforming Healthcare Colorectal Surgical Site Infections (SSIs) Copyright, The Joint Commission

What s next? Joint Commission Center for Transforming Healthcare Colorectal Surgical Site Infections (SSIs) Copyright, The Joint Commission What s next? Joint Commission for Transforming Healthcare Colorectal Surgical Site Infections (SSIs) 1 Public Launch SSI Storyboard 2 COLORECTAL SURGICAL SITE INFECTIONS: CHARACTERISTICS OF THE PROJECT

More information

ACS NSQIP Tools for Success. National Conference July 21, 2012

ACS NSQIP Tools for Success. National Conference July 21, 2012 ACS NSQIP Tools for Success National Conference July 21, 2012 Current and Coming Tools Participant Use Data File (PUF) ROI Calculator Best Practices Guidelines Best Practices Case Studies Quality Improvement

More information

PREVENTION OF POSTOPERATIVE PULMONARY COMPLICATIONS: Reducing Postoperative Mechanical Ventilation

PREVENTION OF POSTOPERATIVE PULMONARY COMPLICATIONS: Reducing Postoperative Mechanical Ventilation PREVENTION OF POSTOPERATIVE PULMONARY COMPLICATIONS: Reducing Postoperative Mechanical Ventilation Rowena Chona O. Sano, MSN, RN, CNL, CPHQ Memorial Hermann Greater Heights Hospital Houston, TX Nothing

More information

University of Washington Medical Center Approach: Using the NSQIP ROI Calculator to Demonstrate Medical Center Cost Savings

University of Washington Medical Center Approach: Using the NSQIP ROI Calculator to Demonstrate Medical Center Cost Savings University of Washington Medical Center Approach: Using the NSQIP ROI Calculator to Demonstrate Medical Center Cost Savings E. Patchen Dellinger, MD Rosemary Mitchell Grant, RN, BSN, CPHQ Disclosures E.

More information

Reliability of Evaluating Hospital Quality by Surgical Site Infection Type. ACS NSQIP Conference July 22, 2012

Reliability of Evaluating Hospital Quality by Surgical Site Infection Type. ACS NSQIP Conference July 22, 2012 Reliability of Evaluating Hospital Quality by Surgical Site Infection Type ACS NSQIP Conference July, 01 Surgical Site Infection Common cause of patient morbidity 5%-6% for colorectal procedures Significant

More information

NOTE: New Hampshire rules, to

NOTE: New Hampshire rules, to NOTE: New Hampshire rules, 309.01 to 309.08 Email Request: Selected Items in Table of Contents: (8) Time Of Request: Sunday, August 07, 2011 18:11:07 EST Send To: MEGADEAL, ACADEMIC UNIVERSE UNIVERSITY

More information

Risk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence

Risk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence Risk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence Adam P. Johnson MD, MPH, Anisha Kshetrapal MD, Harold Hsu MD, Randi Altmark RN, BSN, Herbert E Cohn MD, FACS, Scott

More information

Scrubbing down on Surgical Site Infections: Decreasing the incidence of surgical site infections in children

Scrubbing down on Surgical Site Infections: Decreasing the incidence of surgical site infections in children Scrubbing down on Surgical Site Infections: Decreasing the incidence of surgical site infections in children Tiffany Trenda, DO PGY2, Jessie Allen, DO PGY2, Elizabeth Mack, MD MS, Chris Hydorn, MD, Lori

More information

Finding and Evaluating Events, Developing an Action Plan 9:55-10:15AM

Finding and Evaluating Events, Developing an Action Plan 9:55-10:15AM Session: (GS05) Statistics: Common Core Saturday, July 22, 2017 9:00 AM 10:15 AM Finding and Evaluating Events, Developing an Action Plan 9:55-10:15AM Bruce L. Hall, MD, PhD, MBA Professor of Surgery,

More information

EP20EO Clinical nurses are involved in the review, action planning, and evaluation of patient safety data at the unit level.

EP20EO Clinical nurses are involved in the review, action planning, and evaluation of patient safety data at the unit level. Exemplary Professional Practice CULTURE OF SAFETY EP20EO Clinical nurses are involved in the review, action planning, and evaluation of patient safety data at the unit level. Example B: Provide one example,

More information

Oscar Guillamondegui, MD, MPH, FACS Associate Professor of Surgery Tennessee Surgical Quality Collaborative

Oscar Guillamondegui, MD, MPH, FACS Associate Professor of Surgery Tennessee Surgical Quality Collaborative Oscar Guillamondegui, MD, MPH, FACS Associate Professor of Surgery Tennessee Surgical Quality Collaborative NSQIP 2014 A Collaborative that has Reduced Surgical Site Infections Tennessee Surgical Quality

More information

Welcome and Instructions

Welcome and Instructions Welcome and Instructions For audio, join by telephone at 877-594-8353, participant code 56350822# Your line is OPEN. Please do not use the hold feature on your phone but do mute your line by dialing *6.

More information

Challenges of Sustaining Momentum in Quality Improvement: Lessons from a Multidisciplinary Postoperative Pulmonary Care Program

Challenges of Sustaining Momentum in Quality Improvement: Lessons from a Multidisciplinary Postoperative Pulmonary Care Program Challenges of Sustaining Momentum in Quality Improvement: Lessons from a Multidisciplinary Postoperative Pulmonary Care Program Michael R Cassidy, MD Pamela Rosenkranz, RN, BSN, MEd, and David McAneny

More information

TRANSLATING INSTITUTIONAL DATA INTO UNIT SPECIFIC OUTCOME METRICS USING CUSTOMIZED NURSING SCORECARDS

TRANSLATING INSTITUTIONAL DATA INTO UNIT SPECIFIC OUTCOME METRICS USING CUSTOMIZED NURSING SCORECARDS TRANSLATING INSTITUTIONAL DATA INTO UNIT SPECIFIC OUTCOME METRICS USING CUSTOMIZED NURSING SCORECARDS Debra Campbell, BSN, RN, CPHQ Mary Stevie, MS, RN Cincinnati, Ohio Est. 1889 About TCHHN 621 Bed Tertiary

More information

Choosing and Prioritizing QI Project

Choosing and Prioritizing QI Project Choosing and Prioritizing QI Project July 21, 2017 Anthony T. Petrick MD Director, Minimally Invasive and Bariatric Surgery Geisinger Health System, Danville, PA Co-Chair, MBSAQIP Data and Quality Committee

More information

Expedition: Improving Safety and Reliability for Surgical Procedures

Expedition: Improving Safety and Reliability for Surgical Procedures These presenters have nothing to disclose Expedition: Improving Safety and Reliability for Surgical Procedures Session 5 William Berry, MD, MPA, MPH, FACS Kathy Duncan, RN January 23, 2014 Expedition Coordinator

More information

Surgical Performance Tracking in a Multisource Data Environment

Surgical Performance Tracking in a Multisource Data Environment Surgical Performance Tracking in a Multisource Data Environment Kiley B. Vander Wyst, MPH Jorge I. Arango, MD Madison Carmichael, BS Shelley Flecky, PA P. David Adelson, MD, FACS, FAAP Disclosures No conflicts

More information

Healthcare- associated Infections in North Carolina: A Statewide Discussion

Healthcare- associated Infections in North Carolina: A Statewide Discussion Healthcare- associated Infections in North Carolina: A Statewide Discussion 1 State Stakeholders 2 Agenda Background Data limitations Data review Prevention activities Q&A 3 Goal To discuss HAI prevention

More information

Over the past decade, the number of quality measurement programs has grown

Over the past decade, the number of quality measurement programs has grown Performance improvement Surgeon sees standardization and data as keys to higher value healthcare Over the past decade, the number of quality measurement programs has grown exponentially as hospitals respond

More information

The Use of Patient Audits and Nurse Feedback to Decrease Postoperative Pulmonary Complications

The Use of Patient Audits and Nurse Feedback to Decrease Postoperative Pulmonary Complications The Use of Patient Audits and Nurse Feedback to Decrease Postoperative Pulmonary Complications Christine M. Schleider, RN, BSN Adam P. Johnson, MD, MPH Kathleen M. Shindle, RN, BSN Scott W. Cowan, MD,

More information

Recognize the power of small actions. A simple thank you makes a big difference.

Recognize the power of small actions. A simple thank you makes a big difference. 3M Infection Prevention Solutions Inspiring Change. Changing Lives. Recognize the power of small actions Preventing healthcare associated infections (HAIs) is a complex issue, and there is no single solution.

More information

CPSM STANDARDS POLICIES For Rural Standards Committees

CPSM STANDARDS POLICIES For Rural Standards Committees CPSM STANDARDS POLICIES The Central Standards Committee (CSC) of The College of Physicians and Surgeons of Manitoba (CPSM) is a legislated standing committee of the CPSM and reports directly to the Council.

More information

Strategies to Address All Types of Harm. Objectives. Share implementation process for a successful large scale harm reduction campaign

Strategies to Address All Types of Harm. Objectives. Share implementation process for a successful large scale harm reduction campaign C20 These presenters have nothing to disclose Strategies to Address All Types of Harm Jack Jordan, Partnership for Patients, CMMI William Conway, MD Henry Ford Health System Sam Watson, Michigan Hospital

More information

Consumers Union/Safe Patient Project Page 1 of 7

Consumers Union/Safe Patient Project Page 1 of 7 Improving Hospital and Patient Safety: An overview of recently passed legislation and requirements towards improving the safety of California s hospital patients June 2009 Background Since 2006 several

More information

9/29/2017. Enhanced Recovery After Surgery at the University of Virginia Medical Center. Disclosures. Objectives. None

9/29/2017. Enhanced Recovery After Surgery at the University of Virginia Medical Center. Disclosures. Objectives. None Enhanced Recovery After Surgery at the University of Virginia Medical Center Bethany Sarosiek, RN, MSN, MPH, CNL University of Virginia Health System Charlottesville, VA ErasRN@virginia.edu Disclosures

More information

Effect of Colon Bundle Implementation in a Community Hospital. Michael Barringer, MD, FACS CHS Cleveland

Effect of Colon Bundle Implementation in a Community Hospital. Michael Barringer, MD, FACS CHS Cleveland Effect of Colon Bundle Implementation in a Community Hospital Michael Barringer, MD, FACS CHS Cleveland Doug Hobson, MD, Surgeon Champion Mike Barringer, MD, Surgeon Champion No Disclosures Except for

More information

AMERICAN PEDIATRIC SURGICAL NURSES ASSOCIATION STRATEGIC PLAN

AMERICAN PEDIATRIC SURGICAL NURSES ASSOCIATION STRATEGIC PLAN AMERICAN PEDIATRIC SURGICAL NURSES ASSOCIATION STRATEGIC PLAN 2015-2018 VISION: All pediatric surgical patients will receive the highest quality nursing care that is patient and family centered. MISSION:

More information

AMERICAN COLLEGE OF SURGEONS Inspiring Quality: Highest Standards, Better Outcomes

AMERICAN COLLEGE OF SURGEONS Inspiring Quality: Highest Standards, Better Outcomes AMERICAN COLLEGE OF SURGEONS Inspiring Quality: Highest Standards, Better Outcomes SSI Measure Harmonization ACS NSQIP and CDC NHSN Bruce Lee Hall, MD, PhD, MBA, FACS 2012 ACS NSQIP National Conference

More information

HOSPITAL EPIDEMIOLOGY AND INFECTION CONTROL: SURGICAL SITE INFECTION REPORTING TO CALIFORNIA DEPARTMENT OF PUBLIC HEALTH

HOSPITAL EPIDEMIOLOGY AND INFECTION CONTROL: SURGICAL SITE INFECTION REPORTING TO CALIFORNIA DEPARTMENT OF PUBLIC HEALTH Office of Origin: Department of Hospital Epidemiology and Infection Control (HEIC) I. PURPOSE To comply with reporting cases of surgical site infection as required by Sections 1255.8 and 1288.55 the California

More information

Presented by: Patricia Higazi MSN, RN, COHN Yvette Conyers MSN, RN

Presented by: Patricia Higazi MSN, RN, COHN Yvette Conyers MSN, RN Presented by: Patricia Higazi MSN, RN, COHN Yvette Conyers MSN, RN March 26, 2018 By the end of this session you will: Be familiar with Children s Hospital of The King s Daughters Safety Coach Program

More information

ACS NSQIP Modeling and Data, July 14, Mark E. Cohen, PhD Continuous Quality Improvement American College of Surgeons

ACS NSQIP Modeling and Data, July 14, Mark E. Cohen, PhD Continuous Quality Improvement American College of Surgeons ACS NSQIP Modeling and Data, July 14, 2013 Mark E. Cohen, PhD Continuous Quality Improvement American College of Surgeons Today s presentation on ACS NSQIP statistics 1. An intuitive explanation of our:

More information

MSQC Quality Improvement Initiative Summary- EXAMPLE

MSQC Quality Improvement Initiative Summary- EXAMPLE MSQC CQI Performance Index and Scoring 2014 Attachment D MSQC Quality Improvement Initiative Form MSQC Quality Improvement Initiative Summary- EXAMPLE Goal (Based on MSQC data) Decrease MSQC VTE rate of

More information

Surgeon Champion: Getting Started, What You Need to Know

Surgeon Champion: Getting Started, What You Need to Know Surgeon Champion: Getting Started, What You Need to Know Ninh T. Nguyen, MD, FACS Professor of Surgery Surgeon Champion Vice-Chair, Dept Surgery University of California, Irvine, Medical Center, Orange,

More information

Enhanced Recovery in NSQIP (ERIN): an update on the collaborative. Julie Thacker, LianeFeldman, and Julia Berian ACS NSQIP National Conference 2015

Enhanced Recovery in NSQIP (ERIN): an update on the collaborative. Julie Thacker, LianeFeldman, and Julia Berian ACS NSQIP National Conference 2015 Enhanced Recovery in NSQIP (ERIN): an update on the collaborative Julie Thacker, LianeFeldman, and Julia Berian ACS NSQIP National Conference 2015 No disclosures ERIN, ERAS, and ERP ERIN-Enhanced Recovery

More information

How Data-Driven Safety Culture Changes Can Lower HAC Rates

How Data-Driven Safety Culture Changes Can Lower HAC Rates How Data-Driven Safety Culture Changes Can Lower HAC Rates Session #226, February 23, 2017 Holly O Brien & Abby Dexter Children s Hospital of Wisconsin 1 Speaker Introduction Holly O Brien, MSN RN Safety

More information

Hypertension Management Improvement Automated Cuffs Implementation and Training

Hypertension Management Improvement Automated Cuffs Implementation and Training Hypertension Management Improvement Automated Cuffs Implementation and Training Rae Ann Williams, MD, FACP Regional Assistant Medical Director Jo McLaughlin, MA, BSN, RN Director Nursing and Nutrition

More information

Quality Incentive Programs. By: Amy Yearwood RN, BSN Physicians Network Quality Manager Huntsville Hospital

Quality Incentive Programs. By: Amy Yearwood RN, BSN Physicians Network Quality Manager Huntsville Hospital Quality Incentive Programs By: Amy Yearwood RN, BSN Physicians Network Quality Manager Huntsville Hospital Housekeeping 1. Using the control panel - Use the control panel on the right side of your screen

More information

Frequently Asked Questions: Pediatric Hematology-Oncology Review Committee for Pediatrics ACGME

Frequently Asked Questions: Pediatric Hematology-Oncology Review Committee for Pediatrics ACGME Frequently Asked Questions: Pediatric Hematology-Oncology Review Committee for Pediatrics ACGME Question Answer Introduction How much time should be devoted The Committee expects that the program will

More information

K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals AEA Minimum Participation Full Participation 1, 2

K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals AEA Minimum Participation Full Participation 1, 2 Outcome Measure for Any One of the Following: Outcome Measures Meeting Either A or B: Adverse Drug Events (ADE) All measures are surveillance data Hospital Collected Anticoagulant (ADE-12) Opioid (ADE-111)

More information

Malpractice Litigation & Human Errors. National Practitioners Data Bank. Judging Clinical Competence. Judging Physician Competence.

Malpractice Litigation & Human Errors. National Practitioners Data Bank. Judging Clinical Competence. Judging Physician Competence. Judging Clinical Competence Robert S. Lagasse, MD Professor & Vice Chair Quality Management & Regulatory Affairs Department of Anesthesiology Yale School of Medicine New Haven, CT 64 th Annual Postgraduate

More information

Establishing an infection control accreditation programme to control infection

Establishing an infection control accreditation programme to control infection International Journal of Infection Control www.ijic.info ISSN 1996-9783 Establishing an infection control accreditation programme to control infection Julie Parker Sheffield Teaching Hospitals NHS Foundation

More information

Patient Care Coordination Variance Reporting

Patient Care Coordination Variance Reporting Section 4.8 Implement Patient Care Coordination Variance Reporting This tool provides an overview of patient care coordination (CC) variances, suggestions for documenting and reporting on variances, and

More information

The deteriorating patient recognition and management Dave Story

The deteriorating patient recognition and management Dave Story The deteriorating patient recognition and management Dave Story MBBS, MD, BMedSci, FANZCA Professor and Foundation Chair of Anaesthesia Head of Anaesthesia, Perioperative and Pain Medicine Unit (APPMU)

More information

CMS TRANSPLANT PROGRAM QUALITY WEBINAR SERIES. James Ballard, MBA, CPHQ, CPPS, HACP Eileen Willey, MSN, BSN, RN, CPHQ, HACP

CMS TRANSPLANT PROGRAM QUALITY WEBINAR SERIES. James Ballard, MBA, CPHQ, CPPS, HACP Eileen Willey, MSN, BSN, RN, CPHQ, HACP CMS TRANSPLANT PROGRAM QUALITY WEBINAR SERIES Comprehensive Program and 5 Key Aspects James Ballard, MBA, CPHQ, CPPS, HACP Eileen Willey, MSN, BSN, RN, CPHQ, HACP QAPI Specialist/ Quality Surveyor Educators

More information

Chapter 1 INTRODUCTION TO THE ACS NSQIP PEDIATRIC. 1.1 Overview

Chapter 1 INTRODUCTION TO THE ACS NSQIP PEDIATRIC. 1.1 Overview Chapter 1 INTRODUCTION TO THE ACS NSQIP PEDIATRIC 1.1 Overview A highly visible and important issue facing the medical profession and the healthcare industry today is the quality of care provided to patients.

More information

Clinical Fellowship Acute Pain Service

Clinical Fellowship Acute Pain Service Anesthesia and Perioperative Medicine Western University Acute Pain Service Program Directors Dr. Kevin Armstrong Dr. Qutaiba Tawfic Please visit the Acute Pain Service Fellowship site for most up-to-date

More information

VERIFICATION SURGEON The American College of Surgeons Children s Surgery Verification Program

VERIFICATION SURGEON The American College of Surgeons Children s Surgery Verification Program VERIFICATION SURGEON The American College of Surgeons Children s Surgery Verification Program R. Lawrence Moss, MD Surgeon-in-Chief Nationwide Children's Hospital E. Thomas Boles Jr., Professor of Surgery

More information

Journey Towards Automated. Core Measures at NYP. Scott W. Possley, PA-C, MPAS

Journey Towards Automated. Core Measures at NYP. Scott W. Possley, PA-C, MPAS Journey Towards Automated Click Data to Abstraction edit Master title of CMS style Core Measures at NYP Scott W. Possley, PA-C, MPAS Objectives Describe our hospital Discuss rationale behind automation

More information

2015 Site Survey Information Required Form

2015 Site Survey Information Required Form SITE SURVEY INFORMATION Page 1 Applicant Hospital: Site Survey Date: Information on where Foundation staff should park the van: Person who will meet survey team upon arrival: Location where hospital staff

More information

National Healthcare Safety Network Surgical Site Infection Reporting. Linda Johnson, MA, RN, CPHQ Felicia Alvarez, MPH Sherry Varley, RN, CIC

National Healthcare Safety Network Surgical Site Infection Reporting. Linda Johnson, MA, RN, CPHQ Felicia Alvarez, MPH Sherry Varley, RN, CIC National Healthcare Safety Network Surgical Site Infection Reporting Linda Johnson, MA, RN, CPHQ Felicia Alvarez, MPH Sherry Varley, RN, CIC Objectives Describe the drivers of HAI reporting and improvement

More information

Scope and Significance

Scope and Significance Implementation of a Health and Hospital System Nurse Driven Suicide Screening Protocol Disclosure The speakers have no conflicts of interest to disclose. Kimberly Roaten, PhD Celeste Johnson, DNP, APRN,

More information

Willamette Valley Medical Center Carla Galbraith RN, BSN, CIC Manager Patient Safety/Infection Control November 1, 2013

Willamette Valley Medical Center Carla Galbraith RN, BSN, CIC Manager Patient Safety/Infection Control November 1, 2013 Willamette Valley Medical Center Carla Galbraith RN, BSN, CIC Manager Patient Safety/Infection Control November 1, 2013 About Us Willamette Valley Medical Center McMinnville, Oregon Acute Care Facility

More information

Stanford Multiorgan Transplant Surgery: R-1 Tuesday, February 02, 2016

Stanford Multiorgan Transplant Surgery: R-1 Tuesday, February 02, 2016 Stanford University General Surgery Residency Program Abdominal Transplant Surgery Goals and Objectives for Residents: R-1 Rotation Director: Carlos Esquivel, M.D., Ph.D. Description The Abdominal Transplant

More information

Final Topline The Management and Control of Hospital Acquired Infection Part 3 Orthopaedic Surgery

Final Topline The Management and Control of Hospital Acquired Infection Part 3 Orthopaedic Surgery Final Topline - 26.9.2003 The Management and Control of Hospital Acquired Infection Part 3 Orthopaedic Surgery 96 postal questionnaires returned from 176 Acute NHS Trusts Fieldwork carried out between

More information

Building and Sustaining a Culture of Safety

Building and Sustaining a Culture of Safety Building and Sustaining a Culture of Safety Ann Shimek, MSN, RN, CASC Senior Vice President, Clinical Operations United Surgical Partners International 028 Session Objectives q Describe organizational

More information

POLICY & PROCEDURE POLICY NO: IPAC 3.2

POLICY & PROCEDURE POLICY NO: IPAC 3.2 POLICY & PROCEDURE POLICY NO: IPAC 3.2 SUBJECT SUPERCEDES August 2007, July 2008 S 1of 5 APPROVAL: Infection Prevention & Control Committee DATE: September, 2010 Professional Advisory Committee DATE: January

More information

National Academy of Medicine Leadership Consortium March 23, 2016

National Academy of Medicine Leadership Consortium March 23, 2016 Chrissie Nadzam Blackburn, MHA Principal Advisor, Patient and Family Engagement Institute for Healthcare Quality and Innovation University Hospitals Health System Cleveland, Ohio National Academy of Medicine

More information

REQUEST TO ACCESS EXISTING MEDICAL RECORDS, CHARTS OR DATABASES FOR RESEARCH

REQUEST TO ACCESS EXISTING MEDICAL RECORDS, CHARTS OR DATABASES FOR RESEARCH Steering Committee approved 10/17/11 1. POLICY The Aurora IRB, acting as the HIPAA Privacy Board, is required to review any request for access to medical records, charts or databases maintained by any

More information

VAE PROJECT MASTER ACTION PLAN. Note: Please be aware that these areas overlap to reduce duplication and optimize the synergies

VAE PROJECT MASTER ACTION PLAN. Note: Please be aware that these areas overlap to reduce duplication and optimize the synergies VAE PROJECT MASTER ACTION PLAN Note: Please be aware that these areas overlap to reduce duplication and optimize the synergies Practice NHSN Surveillance Data Collection Is VAE NHSN Surveillance data collection

More information

Membership 101: Recruitment & Retention Strategy

Membership 101: Recruitment & Retention Strategy Please keep this slide in your presentation. Please disclose any vested interest in the second bullet. Membership 101: Recruitment & Retention Strategy The Society of Gastroenterology Nurses and Associates,

More information

Enhanced Recovery Implementing Meaningful Change

Enhanced Recovery Implementing Meaningful Change Enhanced Recovery Implementing Meaningful Change Jeff Simmons MD Associate Professor UAB Department of Anesthesiology and Perioperative Medicine I have no relevant financial relationships to disclose.

More information

Inpatient Quality Reporting Program for Hospitals

Inpatient Quality Reporting Program for Hospitals Inpatient Quality Reporting Program for Hospitals Candace Jackson, RN Project Lead, Hospital Inpatient Quality Reporting (IQR) Program Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR)

More information

The Patient Protection and Affordable Care Act of 2010

The Patient Protection and Affordable Care Act of 2010 INVITED COMMENTARY Laying a Foundation for Success in the Medicare Hospital Value-Based Purchasing Program Steve Lawler, Brian Floyd The Centers for Medicare & Medicaid Services (CMS) is seeking to transform

More information

LOMA LINDA UNIVERSITY MEDICAL CENTER ORTHOPAEDIC SURGERY SERVICE RULES AND REGULATIONS

LOMA LINDA UNIVERSITY MEDICAL CENTER ORTHOPAEDIC SURGERY SERVICE RULES AND REGULATIONS Update 5-18-05 LOMA LINDA UNIVERSITY MEDICAL CENTER ORTHOPAEDIC SURGERY SERVICE RULES AND REGULATIONS I. NAME OF ENTITY The name of this organization shall be the Orthopaedic Surgery Service. II. PURPOSE

More information

Objective Measures CMS TRANSPLANT PROGRAM QUALITY WEBINAR SERIES

Objective Measures CMS TRANSPLANT PROGRAM QUALITY WEBINAR SERIES CMS TRANSPLANT PROGRAM QUALITY WEBINAR SERIES Objective Measures James Ballard, MBA, CPHQ, CPPS, HACP Eileen Willey, MSN, BSN, RN, CPHQ, HACP QAPI Specialist/ Quality Surveyor Educators (QSE s)/ Transplant

More information

Data Collection and Reporting: Why and How

Data Collection and Reporting: Why and How Data Collection and Reporting: Why and How Disclosure Douglas C. Barnhart, MD MSPH FACS I do not have any relevant financial relationships with any commercial interest that pertains to the content of my

More information

AAP SoOr Panel: Comanagement of the Pediatric Orthopedic Patient

AAP SoOr Panel: Comanagement of the Pediatric Orthopedic Patient AAP SoOr Panel: Comanagement of the Pediatric Orthopedic Patient Joshua M. Abzug, MD, FAAP Becca Rosenberg, MD, MPH, FAAP David I. Rappaport, MD, FAAP Disclaimers We have no relevant conflicts of interests

More information

The Intimidation Factor:

The Intimidation Factor: The Intimidation Factor: Workplace intimidation and its effects on wellness, morale, and patient care Disclosure Amanda Chavez, MD, UT Health SA, UHS has no relationships with commercial companies to disclose.

More information

FEATURE. Back to. A Fresh Look at Asepsis BASICS. Alecia Cooper, RN, BS, MBA, CNOR 14 THE OR CONNECTION

FEATURE. Back to. A Fresh Look at Asepsis BASICS. Alecia Cooper, RN, BS, MBA, CNOR 14 THE OR CONNECTION FEATURE Back to A Fresh Look at Asepsis BASICS Alecia Cooper, RN, BS, MBA, CNOR 14 THE OR CONNECTION PATIENT SAFETY A Back to Basics series should start with the principles of asepsis. What does asepsis

More information

Healthcare- Associated Infections in North Carolina

Healthcare- Associated Infections in North Carolina 2018 Healthcare- Associated Infections in North Carolina Reference Document Revised June 2018 NC Surveillance for Healthcare-Associated and Resistant Pathogens Patient Safety Program NC Department of Health

More information

Risk Management in the ASC

Risk Management in the ASC 1 Risk Management in the ASC Sandra Jones CASC, LHRM, CHCQM, FHFMA sjones@aboutascs.com IMPROVING HEALTH CARE QUALITY THROUGH ACCREDITATION 2014 Accreditation Association for Conflict of Interest Disclosure

More information

[Insert organisation logo]

[Insert organisation logo] cleanyourhands campaign Solihull Care Trust Why the campaign? In the 21 st century infections continue to be acquired by patients HCAIs cause the deaths of at least 5000 patients every year and cost the

More information

Karl Bilimoria MD MS Director, ISQIC. Faculty Scholar, American College of Surgeons

Karl Bilimoria MD MS Director, ISQIC. Faculty Scholar, American College of Surgeons Karl Bilimoria MD MS Director, ISQIC Faculty Scholar, American College of Surgeons Director, Surgical Outcomes and Quality Improvement Center Vice Chair for Quality, Department of Surgery Feinberg School

More information

Bariatric Surgery Registry Outlier Policy

Bariatric Surgery Registry Outlier Policy Bariatric Surgery Registry Outlier Policy 1 Revision History Version Date Author Reason for version change 1.0 10/07/2014 Wendy Brown First release 1.1 01/09/2014 Wendy Brown Review after steering committee

More information

ORs in facilities that adopted team training had a lower rate of deaths for

ORs in facilities that adopted team training had a lower rate of deaths for Patient safety VA study shows fewer patient deaths after OR team training ORs in facilities that adopted team training had a lower rate of deaths for surgical patients than facilities that had not yet

More information

Targeted Solutions Tools

Targeted Solutions Tools TARGETED SOLUTIONS TOOL NOW AVAILABLE FOR OUR INTERNATIONAL CUSTOMERS! Joint Commission Center for Transforming Healthcare Targeted Solutions Tools Hand Hygiene Safe Surgery Hand-off Communications Preventing

More information

Patient Safety: Fall Prevention. Unlicensed Assistive Personnel

Patient Safety: Fall Prevention. Unlicensed Assistive Personnel Patient Safety: Fall Prevention Unlicensed Assistive Personnel Purpose and Objectives Purpose: Review the UCH Fall Prevention Program Objectives: 1. Present evidence about patient safety and falls. 2.

More information

Mandatory Public Reporting of Hospital Acquired Infections

Mandatory Public Reporting of Hospital Acquired Infections Mandatory Public Reporting of Hospital Acquired Infections The non-profit Consumers Union (CU) has recently sent a letter to every member of the Texas Legislature urging them to pass legislation mandating

More information

Nurse involvement in quality

Nurse involvement in quality Magnet Excellence Creating and sustaining a clinical environment of nursing excellence By Renee Roberts-Turner, DHA, MSN, RN, NE-BC, CPHQ; Lael Coleman, BA; Gen Guanci, MEd, RN-BC, CCRN; Tina Kunze Humbel,

More information

Accountable Care Organizations: The

Accountable Care Organizations: The Accountable Care Organizations: The Practical Reality BNA Webinar June 2, 2010 Douglas A. Hastings Chair, Epstein Becker & Green, P.C. Member, Board on Health Care Services, Institute of Medicine dhastings@ebglaw.com

More information

2014 Partnership in Prevention Award. November 21, :00-1:00PM EST. Introduction

2014 Partnership in Prevention Award. November 21, :00-1:00PM EST. Introduction 2014 Partnership in Prevention Award November 21, 2014 12:00-1:00PM EST Introduction Don Wright, MD, MPH Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion) U.S. Department

More information

State of California Health and Human Services Agency California Department of Public Health

State of California Health and Human Services Agency California Department of Public Health State of California Health and Human Services Agency California Department of Public Health MARK B HORTON, MD, MSPH Director ARNOLD SCHWARZENEGGER Governor AFL 10-07 TO: General Acute Care Hospitals SUBJECT:

More information

Frequently Asked Questions: Child Abuse Pediatrics Review Committee for Pediatrics ACGME

Frequently Asked Questions: Child Abuse Pediatrics Review Committee for Pediatrics ACGME Frequently Asked Questions: Child Abuse Pediatrics Review Committee for Pediatrics ACGME Question Answer Introduction How much time should be devoted The Committee expects that the program will provide

More information

A Resident-led PICU Morbidity and Mortality Conference

A Resident-led PICU Morbidity and Mortality Conference A Resident-led PICU Morbidity and Mortality Conference James Moses, MD, MPH Associate Program Director Boston Combined Residency Program Director of Patient Safety and Quality Department of Pediatrics

More information

Quality Management and Accreditation

Quality Management and Accreditation Quality Management and Accreditation Lina Mekawi, RPh, MS Epidemiology, CPHQ, Senior Quality Analyst, Quality, Accreditation and Risk Management Department, AUBMC November 2017 Disclosure Slide I, Lina

More information

Title: Quality/Safety Education Physician Champion Phone:

Title: Quality/Safety Education Physician Champion   Phone: TeamSTEPPS 101: Know The Plan, Share The Plan Implementing A Customized Surgical Safety Checklist Team Communication Tool In Ambulatory And Inpatient Operating Rooms Organization Name: Christiana Care

More information

Sepsis, An Interdisciplinary and Collaborative Approach. Bassett Medical Center October/November 2017

Sepsis, An Interdisciplinary and Collaborative Approach. Bassett Medical Center October/November 2017 Sepsis, An Interdisciplinary and Collaborative Approach Bassett Medical Center October/November 2017 Bassett Medical Center 180 bed acute care inpatient teaching facility in Cooperstown, New York is the

More information

Privacy Rule Overview

Privacy Rule Overview Privacy Rule Overview Protected Health Information (PHI) is private information that is subject to special treatment under the HIPAA Privacy Regulations. PHI can only be used or disclosed in research if

More information

Canadian Surgical Site Infection Prevention Audit Month

Canadian Surgical Site Infection Prevention Audit Month Canadian Surgical Site Infection Prevention Audit Month February 2016 CONTENTS KEY FACTS...3 SSI PREVENTION AUDIT RESULTS...3 BACKGROUND...4 METHODOLOGY...4 Data Scores... 5 How to Interpret the Indicator

More information

Alberta Health Services. Strategic Direction

Alberta Health Services. Strategic Direction Alberta Health Services Strategic Direction 2009 2012 PLEASE GO TO WWW.AHS-STRATEGY.COM TO PROVIDE FEEDBACK ON THIS DOCUMENT Defining Our Focus / Measuring Our Progress CONSULTATION DOCUMENT Introduction

More information

National Priorities for Improvement:

National Priorities for Improvement: National Priorities for Improvement: Standardization of Performance Measures, Data Collection, and Analysis Dale W. Bratzler, DO, MPH Principal Clinical Coordinator Oklahoma Foundation Contracting for

More information

Learning Session 3: CDI Tracer and Assessment Tool

Learning Session 3: CDI Tracer and Assessment Tool National Nursing Home Quality Care Collaborative (NNHQCC) II and the Clostridium difficile Infection (CDI) Initiative Learning Session 3: CDI Tracer and Assessment Tool Health Services Advisory Group (HSAG)

More information