1. Hospital Outpatient Department Quality Measures National Hospital Quality Measures Team Members Anesthesia Surgical Services Labor & Delivery Nursing Education Electrophysiology Lab Urology Department Medical Records EPIC Quality Resource Management Center for Clinical Effectiveness

2. Confidential: For Quality Improvement Purposes Only Surgical site infections are a major complication after surgery, resulting in considerable morbidity, mortality, and resource utilization. Proper use of antibiotics- giving the right drug at the right time-is effective in preventing infections after surgery. Opportunity Statement

3. Confidential: For Quality Improvement Purposes Only Hospital Outpatient Quality Data Reporting Program National Program Progression of CMS Value-based purchasing plan. Program is modeled on the current quality data reporting system for inpatient services (Core Measures: Heart Failure, Pneumonia, SCIP & AMI) To meet requirements and receive full reimbursement for CY 2008 services, hospital must submit data for seven quality measures, if applicable. Failure to report data will incur a reduction in their annual payment update factor by 2%. HOP QDRP

4. Confidential: For Quality Improvement Purposes Only Force 7: Quality Improvement Force 11: Nurses as Teachers Force 13: Interdisciplinary Relationships Forces of Magnetism

5. Confidential: For Quality Improvement Purposes Only Administer antibiotics within one hour before surgical incision Administer appropriate antibiotic identified for select procedures AIM STATEMENT

6. Confidential: For Quality Improvement Purposes Only Met with specific out-patient surgical areas to introduce project and identify improvement opportunities –Lack of consistent documentation of procedure start times –Lack of consistent documentation of antibiotic administration –Lack of consistent documentation for use of Vancomycin –Use of appropriate antibiotic Department Specific Initiatives

7. Confidential: For Quality Improvement Purposes Only Outpatient Surgical Care Perioperative Care: Timing of Antibiotic Prophylaxis Perioperative Care: Selection of Prophylactic Antibiotic –Departments Involved: Ambulatory Surgery Center, Main OR, EP Lab, Labor/Delivery, & Urology –Over 200 Procedure Codes –Types of Surgeries: Cardiac: Pacemaker revisions, battery change-outs Vascular: grafts Genitourinary: Transrectal prostate biopsy Gastric biliary: peg placements, laparoscopic appendectomy Gynecology: Vaginal hysterectomy, synthetic pubovaginal sling Head and Neck: Treatment of jaw fractures Quality Measures

8. Confidential: For Quality Improvement Purposes Only Analysis: Patients received the proper prophylactic antibiotics within one hour of surgery start time 87% of the time. Knowledge deficits of project requirements and lack of proper documentation of required elements are identified as opportunities for improvement in this new imitative. Last month’s data demonstrate improvement towards stretch goal of 95%. Stretch goal 95% Project begins 4/1/4008 Correct Antibiotic Selection

9. Confidential: For Quality Improvement Purposes Only Analysis: Patients received prophylactic antibiotics within one hour of surgery start time 79% of the time. Knowledge deficits of project requirements and lack of proper documentation of required elements are identified as opportunities for improvement in this new imitative. Last two months demonstrate improvement towards stretch goal of 95%. Project begins 4/1/2008 Stretch goal: 95% Antibiotics Within One Hour of Surgery/Procedure Start Time

10. Confidential: For Quality Improvement Purposes Only Develop physician specific reports for results Educate departments on initiative and opportunities for improvement Report to key stakeholders Re-education of data abstractors to changing specifications Next Steps