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Quality Improvement Initiatives
Continuous Improvement has been a way of doing business at NMC for years. It started out as a management development topic and has become how we go about daily life. As a community hospital, we must always search out better ways to do things in order to remain a viable, vital organization. We are constantly looking to improve patient care, enhance patient satisfaction, increase employee safety, operate with greater efficiency, and achieve better outcomes. The uniform format of the Act 53 report card calls for descriptions of three new quality improvement projects. We are pleased to provide overviews of our efforts to: Surgical Care Improvement, Operational Improvements in the Emergency Department, and Expansion of Access to CT Services.
Project Name: Surgical Care Improvement
Situation Description: Building on the “Surgical Site Infection” quality improvement initiative highlighted in last year’s Act 53 Community Report, the NMC Surgical Services Department took on an effort in 2006 to improve Surgical Care on a broader scope, with an emphasis on the Surgical Care Improvement (SCIP) Core Measures.
Through the SSI project, we had focused on being at 100% on monthly basis with the core measures of the timing of antibiotics, the selection of the proper antibiotic, and the discontinuation of antibiotics within 24 hours. As we neared that goal, we found that there continued to be inconsistencies with our other surgical core measures. We then committed to achieving 100% on the other surgical Core Measures. Our hypothesis was that if we were able to achieve 100% on the Core Measures in Surgery, we would see a reduction in our surgical site infection rate – which was already below the national average.
Project Goals & Measures:
- To be at 100% on a monthly basis for the Surgical Care Improvement (SCIP) measures (which now include the Surgical Site Infection (SSI measures);
- To reduce our overall rate of surgical infections.
Intervention Description: To move from inconsistent performance to 100% achievement of Core Measures in Surgical Services, a number of interventions were used. Physicians were engaged and educated regarding their role in the Core Measures. There was a significant amount of education for the nursing staff regarding the Core Measures and what they could do to facilitate 100% achievement. The roles and relationships of the NMC Quality Council and the data abstracters were adjusted to provide additional scrutiny of our approach to Core Measures. Expectations and accountability were clarified throughout the organization.
In addition, a number of measure-specific improvements were implemented to refine our approach and standardize processes. Perhaps most notable of these was the implementation of guidelines regarding deep vein thrombosis. This helped ensure the properly timed use of the right kind of blood thinner, stockings to promote blood flow, and veiniflos to promote blood flow – as medically appropriate in keeping with the Core Measures.
Evaluation & Results: NMC is now consistently at or very near 100% on the Surgical Core Measures on a monthly basis. Updated graphs of hospital’s performance can be found in the Quality section of the NMC website. In addition, NMC is beginning to see the hypothesized reduction in surgical site infection rates as a correlate of the improvements in Core Measures – even upon a rate that was already below the national average. In our work on deep vein thrombosis, we have seen improvement in our core measures and hope our latest round of process changes will bring us up to 100%.
Contact Information:
Cheri Losito, Surgical Services Nurse Manager
Northwestern Medical Center
PO Box 1370, St. Albans, VT 05478
524-1073 * 524-1251 (fax) * closito@nmcinc.org
Project Name: Operational Improvements In The Emergency Department:
Situation Description: Northwestern Medical Center has one of the busiest Emergency Departments in the State, seeing more than 25,000 patients on an annual basis. Our patient satisfaction and other key indicators have traditionally been positive as they related to Emergency Department care. However, our staff eagerly accepted the opportunity to seek further improvements when the Institute of Health Improvement (IHI) offered its related learning community. Given the nature of the care provided, and the volume of care provided, it was felt any improvement would be beneficial to our community. Tests of change for this project began in November of 2006.
Project Goals & Measures:
- Length of stay from arrival to discharge for all patients will be less than 180 minutes 90% of the time and less than 60 minutes for intermediate care / fastrack patients 90% of the time;
- Laboratory and Diagnostic Imaging orders will be completed within 45 minutes 90% of the time;
- Nurse-to-Nurse and Physician-to-Physician handoffs will be completed at the bedside using SBAR communications format 100% of the time when not contra-indicated by the nature of the emergent situation;
- Acute Myocardial Infarction (AMI) and Pneumonia core measures will be at 100%;
- Patient satisfaction ratings for four key indicators (being informed of expected time frames, understanding treatment, giving input into care, and recommending our ED to others) will be at the 5-star rating level.
Intervention Description: The NMC Emergency Department Staff and Physicians are actively participating in the “Operational Improvements in the Emergency Department” learning community offered at the national level through the Institute of Health Improvement (IHI). Numerous interventions have been implemented, including:
- Pre-identification of the next available bed (“bed ahead”) for a patient to be admitted to the hospital to speed time of admission for a patient once that clinical decision has been made;
- Use of electronic tracker board information to speed the movement of patients between the ED and Diagnostic Imaging;
- Relocating the antibiotic storage from the Pharmacy to the ED to speed the administration of certain medications;
- Experimenting with bedside registration of Emergency Department patients;
- Adoption of SBAR communication for nurse-to-nurse and physician-to-physician, as well as the extension of this approach to pre-hospital providers for EMS-to-ED communications; etc.
Evaluation & Results: The initial results of the “bed-ahead” test of change were very promising in terms of reducing LOS within the Emergency Department, but recently have started to trend back upwards, so must be revisited. SBAR communication has been particularly well received and should generate measurable improvement. Other tests of change are still in their initial phases and have not produced definitive results at this time. NMC’s compliance with core measures is at or near 100% -- updated graphs on the AMI and Pneumonia core measures are available on the Quality section of the NMC website. We continue to be very excited about the ED Operational Improvements effort and confident it will deliver measurable improvements for our patients.
Contact Information:
Molly Grismore, Emergency Department Nurse Manager
Northwestern Medical Center
PO Box 1370, St. Albans, VT 05478
524-4307 * 524-1053 (fax) * mgrismore@nmcinc.org
Project Name: Expansion of Access to CT Services
Situation Description: In July of 2006, NMC’s Diagnostic Imaging Department was booking CT-Scans out 10-14 days. This created dis-satisfaction among patients and referring physicians. In addition, the limitations of access adversely impacted our ability to accommodate inpatient scans and emergent scans without disrupting the outpatient schedule. As a result, the Diagnostic Imaging Department took on the challenge of expanding access to CT services – without the option of a million dollar investment in an additional CT Scanner or the addition of staffing hours to boost access.
Project Goals & Measures:
- Reduce wait time for the scheduling of a CT-Scan to next-day or same-day without incurring additional capital costs or an increase in ongoing staffing costs.
Intervention Description: While the knee-jerk reaction to increasing access might be to purchase additional equipment and hire additional staff, NMC’s DI staff thought creatively, truly embodying the organizational values of efficiency and progress and our emphasis on process improvement.
- The staff identified a bottleneck in the CT-Scan process. Prepping patients in the same room as the CT-Scanner is the traditional approach – but it prevents the machine from being used during patient prep. A staff member identified the opportunity to convert an under-utilized utility room into a “prep room” to clear time in the CT Room solely for the taking of images.
- The ability to schedule CT exams was also limited by the availability of CT-trained DI Techs. By cross-training existing staff into the CT modality, the DI Department was able to expand the hours of CT earlier in the day and later in the day – with incurring additional ongoing staffing expense.
Evaluation & Results: This project has been a tremendous success. There are now 16 CT slots in the daily DI schedule, up from 8 prior to the project, without capital costs. Hours have been expanded from 8am-4:30pm to 7am-7pm, without additional ongoing staffing costs, resulting in greater satisfaction from patients who were seeking appointments before and after work. The schedule now allows for the timely accommodation of emergent cases and inpatient imaging – without disrupting access for scheduled outpatients. In terms of the overall goal, access to CT has been improved from a 10-14 day wait to the target of same-day or next-day availability, thanks to the creative approach of our DI staff. This project has inspired similar and successful efforts to improve access in Mammography, Ultrasound, and MRI.
Contact Information:
Mark Sutton, Diagnostic Imaging Manager
Northwestern Medical Center
PO Box 1370, St. Albans, VT 05478
524-1058 * 524-1289 (fax) * msutton@nmcinc.org
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