January 2009 Volume 33 No. 1

Quality Corner

November Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee [QIPSC],
chaired by Joseph Hopkins, associate chief of staff

Many of the items we’ve discussed in this column over the past few years involve admonitions and plans to improve quality and reduce errors. This month I’m glad (call it a New Year’s gift) to present some results of how carefully designed “best practices” have resulted in safer, more effective medicine for our patients. This month I have three interim successes to report:

First, the O/E (observed to expected) general surgery mortality ratio of 0.56 puts Stanford first out of 98 institutions on this clearly fundamental measure of quality. The entire general surgery team — physicians, nurses and everyone involved — deserves kudos for being the best by relentlessly applying quality principles — every time. Overall during the past 12 months, SHC’s O/E mortality is 26th out of the 98 benchmark institutions we are compared with. So we have room for progress there.

Another area where we had not been performing as well as we had liked but are doing better now is in the American College of Cardiology Registry performance on “door to balloon” for STEMI (ST-elevation myocardial infarction). Before we adopted the STEMI Door to Balloon initiative in 2007, only 58.3 percent of patients were under the target of less than 90 minutes. Since then, as a result of applying this ACC “best practices” protocol in the Emergency Department and Cath Lab, this number has increased to 90.3 percent for the four most recent quarters. This places us in the top 8 percent of hospitals nationally in terms of meeting the 90-minute target. Again, this is a prime example of a practice that pays dividends very quickly.

Next, a nursing-driven protocol is paying dividends. The Integrated Nurse leadership Program (INLP) Medication Administration Project has sharply reduced medication errors on two pilot units and is now being recommended for expansion to all 15 nursing units at SHC. Results showed 98.8 percent accuracy from the initial pilot on medical/surgical unit F3. The most significant change was establishing a designated “medication time out” for passing medication during which nurses should not be interrupted. Resource nurses handled urgent problems during these times. Among other measures undertaken was a system to cross check the medication delivered to the patient with the medical administration record (MAR) and restructuring RN and NA responsibilities to provide more focus on this crucial activity. It’s important to note that this initiative was nursing driven, a professional boost that can only encourage and empower nurses to seek solutions benefitting everyone in our hospital.

Sometimes the dividends we receive involve cost reduction as well as quality improvement. Platelet wastage decreased a jaw dropping 9.9 percent from 11.4 percent in March ’07 to 1.5 percent in the third quarter of 2008, resulting in a savings of $235,000. Total waste of blood products was 0.9 percent in the 3rd quarter of 2008, down from 1.4 percent in the last quarter of 2007. Frozen plasma wastage dropped from 7.7 percent in October 2007 to 1.5 percent in the third quarter of 2008. In the same arena, our ration of cross match to transfusion is edging toward the level of the top 10 hospitals nationally.

We have made progress, we have more progress to make, and we have a new year to continue or efforts and vigilance. Happy New Year.