1. Image/Figure Surgical Performance Improvement in a Health System -
ACS NSQIP and a System Surgical Council
as a Driver for Change
Participation in ACS NSQIP provides the foundation for collaboration and continuous improvement in a health care system. Hartford Healthcare Surgical Council brings its surgical departments together under the banner of NSQIP, with a vision to create a single standard of surgical best practice. Local initiatives at system hospitals gain a step-up, with the advantage of shared lessons and system wide solutions.
A Surgical Council was established in 2013 to create a single standard of surgical care across a diverse healthcare system. At its inception each of the five hospitals, ranging from small community to tertiary care centers, had variable approaches to data and processes, and different cultures. ACS NSQIP was implemented as the vehicle for measuring outcomes. Council members include system medical and quality directors, surgical chiefs, surgeon champions and surgical clinical reviewers.
American College of Surgeons NSQIP Participation
Image/Figure
Monthly Quality Dashboard Review
Surgical Services Performance Improvement Committees (interdisciplinary) at each hospital
Sharing site specific quality initiatives
Colorectal Subcommittee
VTE – Patient Safety Indicator 12
System Value Analysis and Standardization
High quality outcomes through best practice
Product and equipment standardization
Economies of scale and cost reduction
System wide IRB for emerging technologies
Sharing Our Stories: Successes and Opportunities
Scheduled reporting to system Peri-op Council
Partnering with other Clinical Councils
Bidirectional communication with hospital Departments of Surgery and Peri-op
Safety stories shared across system
Reporting to Quality Boards
Regional and National Presentations
Rekha Singh MD FACS, Sharon Weintraub MD MPH FACS, Cynthia Ross-Richardson MS RN CNOR, Mary Beland MSN RN CNOR, Jay Encarnacion RN BSN,
Linda Wood MSN, Patricia Sobieski RN BSN CPHQ, Patricia Blake RN BSN, Samantha Grable RN, Rafal Barczak MD FACS, Michael Posner MD FACS MBA,
David Kalla MD, Leszek Kolodziejczak MD, Joseph Portereiko DO FACS, Orlando Kirton MD FACS MCCM FCCP, Rocco Orlando MD FACS