Improving Compliance

Improving Compliance

* The following planners, speakers, moderators, and/or panelists of this CME activity have no relevant financial relationships with commercial interests to disclose: Mary B. Johnson BSN RN

Measure March 2012 March 2013 March 2014 Prophylactic antibiotic < one hr. prior to incision Appropriate prophylactic antibiotic selection Prophylactic antibiotic dc d within 24 hrs. Cardiac sx. with blood glucose POD 1 and POD 2 < 200 100% 21/21 100% 23/23 100% 23/23 100% 21/21 100% 23/23 100% 23/23 95% 19/20 100% 22/22 100% 21/21 100% 7/7 100% 6/6 100% 4/4 Appropriate hair removal 100% 30/30 100% 33/33 100% 34/34 Beta blocker prior to sx. and POD 1 and 2 100% 13/13 100% 11/11 100% 17/17 Appropriate VTE ordered 95% 19/20 100% 23/23 100% 23/23 Appropriate VTE given < 24 hrs. after anesthesia end time 90% 18/20 100% 23/23 100% 23/23 Foley removal by end POD 2 100% 17/17 100% 21/21 100% 22/22 Perioperative temp. mgmt. 100% 29/29 100% 29/29 100% 33/33 Composite 97.98% 194/198 100% 191/191 100% 200/200 Bundle 90% 27/30 100% 33/33 100% 35/35

* *Leadership support *Developing awareness through education *Empowerment of nursing staff *Teamwork *Transparency *Creativity *Trust

All staff and physicians were taught and continue to be taught the basics starting at orientation, as well as through email blasts, computer training, skill fairs, and one on one as needed: * Prophylactic antibiotic < one hr. prior to incision (timing of antibiotic added to time out procedure) * Appropriate prophylactic antibiotic selection (appropriate antibiotic added to time out procedure) * Prophylactic antibiotic discontinued within 24 hrs. * Cardiac surgery with blood glucose 18-24 hrs. < 180 * Appropriate hair removal * Beta blocker prior to surgery and POD 1 and 2 (Anesthesia to assure that beta blocker has been given preoperatively) * Appropriate VTE ordered and administered within 24 hrs. of anesthesia end time * Foley removal by end POD 2 Normothermic temperature maintained throughout surgery *

*The previous day s OR log is checked daily for all patients that might be a SCIP patient (inpatients and outpatients). * Using the form that has been created, all possible SCIP patients are abstracted. This will include add-on cases. * Once all abstraction is completed each morning, the charge nurse of each floor is called to let him/her know what measures must be completed by the end of the day if they have not already been done (i.e.. beta blocker needs to be ordered and given, foley needs to come out, antibiotic must be discontinued by a certain time, etc.). This will necessitate building a relationship with the charge nurses.

*Each SCIP patient is abstracted for 2 days postoperatively to assure that all measures for POD 1 and POD 2 have been met. *File concurrent forms in a monthly folder, by discharge date, to be used for CMS retrospective monthly abstraction. *If a measure is not met (falls out) by a surgeon: a noncompliance letter that details the noncompliance and signed by the Director of Surgery, is sent to the surgeon. A copy of the letter is kept in the surgeon s file for OPPE. *If a measure is not met (falls out) by a nurse: a noncompliance letter that details the noncompliance, and is signed by the Director of Nursing is sent to the nurse. A copy of the letter is kept in the nurse s HR file.

*Monthly or quarterly reports are given at Surgery, Quality, Clinical Best Practice and other hospital- wide meetings that demonstrate all SCIP compliance and fallouts. These reports are unblinded as to the surgeon or nurse that caused the fallouts. This awareness has improved compliance significantly. *Leadership at Florida Hospital Waterman has been 100% supportive of the efforts of the Quality Improvement Initiatives taken to assure that the best care is delivered to the patients and that 100% compliance is obtained in all quality core measures. *July 1, 2014, equality was started house wide. This is an electronic system for Quality Measure abstraction that begins at admission and is completed at discharge for all patients. We are always seeking new opportunities to provide better care and therefore better outcomes for our patients.