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
Disclosures Nothing to disclose
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 th busiest pediatric surgical program in U.S. 485+ pediatric surgery experts, each with a passion for quality, each with a personal vision for what quality is
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
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
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
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
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
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
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
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