Surgical Care Improvement Project Initiatives

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Surgical Care Improvement Project Initiatives
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Performance Improvement Initiatives Taken to
Improve SCIP Scores

• Performance Improvement Team Formed
• Director of Perioperative Services
• Chief of Surgery
• Director Quality
• Clinical Nurse Managers

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Areas Determined Needing Improvement

• Education and support from physicians
• Education of clinical staff
• Timely and accurate documentation
• Concurrent review of medical record
• Accountability

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Education and Support with Physicians

• Education and approval of clinical practice
  changes by the Medical Executive Committee and
  the Surgery Committee
• Individualized education for each physician by
  the Director of Perioperative Services and the
  Chief of Surgery

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Practice Change

• Preoperative order sets for all physicians
  reviewed and updated
• Clinical nurse manager in Out Patient Surgery
  monitored compliance on a daily basis
• Encouraged physicians to use Clindamycin instead
  of Vancomycin when patient had allergy to
  Penicillin

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Education of Clinical Staff

• Provided department specific education
• Obtained a Champion in every department
• Encouraged staff ownership of SCIP
• Individualized reeducation when warranted
• Reported progress frequently to staff

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Timely and Accurate Documentation

• Assessed current documentation
• Worked with abstractors to find out what
  specifically needed to be documented and where
  they were allowed to abstract the information
  from in the medical record
• Revised medical record forms
• Educated clinical staff on documentation
  requirements

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Concurrent Review

• Man hours dedicated to daily review of compliance
  to standards and documentation
• Individualized education to clinical staff and
  physicians when failure to comply occurred
• Information Systems joined the Performance
  Improvement Team and developed computerized
  reports to assist clinical staff with concurrent
  review

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Accountability

• Physician compliance documented and reported
  through peer review
• Clinical staff monitored for compliance and this
  was reflected in their annual review

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Actions that Facilitated the Most Improvement

• Dedicated staff for concurrent review
• Individualized clinical staff re-education
• Anesthesia record revised
• Standardized physician pre-operative and
  post-operative order sets
• Department champions

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Sustaining the Gain

• Continue concurrent review
• Accountability
• Reporting of successes and failures on a routine
  basis

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Questions?