3. Mission To provide exceptional care to every patient every day with a spirit of warmth, friendliness and personal pride. Values - I.C.A.R.E. Integrity Compassion Accountability Respect Excellence Vision Exceptional Care, Customer Loyalty, Financial Strength PI

4. Texas Award for Performance Excellence Same criteria and process as the Malcolm Baldridge National Quality Award! Awarded to organizations that serve as role models for quality, customer satisfaction, and performance excellence in Texas Texas Health Care Quality Improvement Award Awarded by TMF® Health Quality Institute, the Medicare Quality Improvement Organization for Texas PI

5. Interviewee: Shannon Kane-Reinhardt RN, BSN, Quality Manager (St David’s Round Rock Medical Center) Interviewers: Lombe Chitundu Jean Cusick Yolanda Johnson Vicki McGinnis Sharon Royall-Murphy Interview Date: March 30, 2010 PI

6. Step 5: Perform Ongoing Monitoring Step 4: Identify Improvement Opportunity Step 3: Analyze and Compare Data Step 2: Measure Performance Step 1: Identify Performance Measures 5 Steps in an Organizational PI Model

7. PI Core Measures SCIP Antibiotic Received Within One Hour Prior to Surgical Incision (SCIP-Inf-1a)

8. PI

9. Create confidential spreadsheet: Anesthesia Start Date Admission Date Antibiotic Administration Route Antibiotic Name Antibiotic Received Birth date Clinical Trial Discharge Date ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code Infection Prior to Anesthesia Laparoscope Oral Antibiotics Other Surgeries Areas Studied and Data Collection

10. PI Measurement Ratio Number of surgical patients with antibiotics initiated within one hour prior to surgical incision All selected surgical patients with no evidence of prior infection.

11. PI  Data added to spreadsheet: Name of surgeon Case identifier Date of surgery Reason for outlier (why not started on time) Responsibility (who started antibiotic)  Analyze all outliers Operating Room Timeout Checklists

12. PI

13. SCIP Champions Directors Frontline Managers Staff Multidisciplinary PI Team

14. PI Board of Directors CMO Quality Executive Committee Organization Wide Dashboard (Report Card) PI Internal Communications

15. PI PI Cycle Computer System Changes OR Charting Module Rollout PI Process Issues (Outliers) Process change(s) in other areas Forces driving ongoing improvement efforts

16. PI The hospital indicated that the data submitted for this measure were based on a sample of cases. HCAHPS Customer Satisfaction Survey