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 Act Check Plan PDCA Do

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 Act Check Plan PDCA Do

5. Interviewee: Shannon Kane-Reinhardt RN, BSN, Quality Manager Interviewers: Lombe Chitundu Jean Cusick Yolanda Johnson Vicki McGinnis Sharon Royall-Murphy Interview Date: March 30, 2010 Act Check Plan PDCA Do

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 Act Check Plan PDCA Do

7. Core Measures SCIP Antibiotic Received Within One Hour Prior to Surgical Incision (SCIP-Inf-1a) Act Check Plan PDCA Do

8. Act Check Plan PDCA Do

9. Hospital Areas Studied Act Check Plan PDCA Do

10. Data Collection Process Name of surgeon Date of surgery Surgical procedure (ie. CABG, Cardiac) OR Module Chart Antibiotic Administration Route Antibiotic Name Antibiotic Received Anesthesia Record Sampling of Surgical Patients Confidential Spreadsheet Act Check Plan PDCA Do

11. 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. Act Check Plan PDCA Do

12.  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 Act Check Plan PDCA Do

13. Act Check Plan PDCA Do

14. External Performance Reporting Act Check Plan PDCA Do

15. SCIP Champions Pharmacy OR Services Pre-op, OR, PACU OrthoAnesthesiaQuality Information Services (IS) Multidisciplinary PI Team Act Check Plan PDCA Do

16. Board of Directors CMO Quality Executive Committee Leadership Team Dashboard (Report Card) Organization-wide PI Communications Act Check Plan PDCA Do

17. PI Cycle Computer System Changes OR Charting Module Rollout PI Process Issues (Outliers) Process change(s) in other areas Factors influencing ongoing improvement efforts Act Check Plan PDCA Do

18. Act Check Plan PDCA Do Core Measure Set – SCIP ( 289/296= 97.64%; Benchmark 98.23%) Missed ElementReason for MissAction Antibiotic Selection (40/42=95.24%) Outlier 1 Hysterectomy. Patient was given Cleocin and Gentamycin antibiotics. No documentation of an beta lactam allergy. Per CMS guidelines these two antibiotics are recommended only if patient has a beta lactam allergy. 1) Pharmacy and Quality review of preoperative antibiotics. 2) Outlier provider letters Outlier 2 Hysterectomy. Patient was given Cleocin and Gentamycin antibiotics. No documentation of an beta lactam allergy but patient did have an allergy to erythromycin. Per CMS guidelines these two antibiotics are recommended only if patient has a beta lactam allergy. VTE Ordered (38/40=95%) and VTE Received (37/40=92.5%) Outlier 4 and 5 Exploratory Laparotomy. No pharmacological VTE prophylaxis was ordered within 24 hours after surgery end-time. There is no documentation of a contraindication to VTE prophylaxis. Hospitalist documented "? Lovenox" in the progress notes and wrote an order for Lovenox "if okay with surgeon". Surgeon ordered the Lovenox outside of the 24 hour timeframe. Per CMS guidelines VTE prophylaxis needs to be ordered and given within 24 hours of surgery. Major case, new physician, More focus on time sensitive measures and major cases. Outlier 6 and 7 Exploratory Laparotomy. Lovenox was not ordered on patient during hospitalization. Surgeon queried. No contraindication to pharmaceutical VTE noted. Major case, not followed timely by concurrent review. Surgeon willing to help champion a General Surgery order set. Outlier 8 Exploratory Laparotomy. Lovenox was ordered on POD 1 as a "now" order. Nursing had approximately 1 hour to administer within the SCIP 24 hour window. Patient did not received the Lovenox until approx 6 hours later. Same Surgeon as outlier 6 and 7. Nursing outlier review. Executive Summary of Action Plans

19. The hospital indicated that the data submitted for this measure were based on a sample of cases. HCAHPS Customer Satisfaction Survey Act Check Plan PDCA Do