Building NSQIP Across FHDonna Rolph Nov 2012

Background on FHFH has 12 hospitals extending from Burnaby to White Rock to Boston Bar

We serve >1.5 million residents

We have >26,000 employees

Background on FH in NSQIP

Three sites were early members:

Surrey Memorial Hospital

Royal Columbian Hospital

Burnaby Hospital

June 2011…..

Very dedicated SC taking NSQIP to whomever would listen

Very dedicated and qualified staff Staff working looooong hours to get

data in before lock-out Silos Spread of NSQIP very slow

FH NSQIP Focus in 2011-2012

Establishing organizational structures

Staffing & CompensationSurgical Clinical ReviewersSurgeon ChampionsNSQIP Office ClerksNSQIP Quality Improvement ConsultantsSetting up offices at each site

FHA NSQIP ORGANIZATIONAL CHART

Team Building

3-day workshop to formulate mission, vision, values

Strengthening Individual competencies

Establishment of teams

FH NSQIP Focus in 2012-2013

Using data to set goals at each site

Analyzing the data

Getting the word out about NSQIP internally

Sending Surgical Clinical Reviewers and frontline staff to the Quality Academy

Sustainability of goals

FH NSQIP Focus in 2012-2013

Action teams up and running at all sites

Bulletin boards on every surgical unit with data and updates of team work

Reducing postsurgical complications Getting the word out beyond FH

Demonstrating a return on investment

Where are we at? NSQIP at 10 of 11 sites

New sites spreading what NSQIP is ERH/RM/JP; ERH/CGH have had open houses

Teams at BH, LMH, ARH, SMH, PAH, DH

CUSP at RCH with John Hopkins

Five of our teams are presenting here (BH-pneumonia px; PAH- Wound classification; LMH-UTI; SMH-UTI; PAH-CAUTI

Where are we at?

Research at 2 sites. LOI accepted proposals being written

Articles for publication—2 planned for Dec/12

NSQIP invited to provincial PACU workshop (Ronelle and Kim) represented us

Standardizing of processes, report template, clerk orientation manual (draft)

Sept 27 Workshop for region 140 attended

Where are we at? We have working teams: Orientation/Education;

Technology, Research/Publishing, Communications/Marketing, Business Management, NSQIP Resource Team

Agenda item at: QI Rounds; Surgical Operations (Directors and Managers); QI Improvement (Dr Committee); Executive Report monthly; Infection control monthly meeting

FH NSQIP:Mission:

Connecting Healthcare providers with quality data to improve outcomes for surgical patients

Vision: FH NSQIP leading the way in

providing optimum patient outcomes