Surgical Services Clinical Program works to improve patient safety

Clinical Focus on Quality

The Surgical Services Clinical Program was established in 2005 and is Intermountain's newest clinical program. This clinical program is accountable for patient care throughout the Peri-Operative arena, including Operating Rooms, Ambulatory Surgery Centers, Anesthesia, Same Day Surgery, Post Anesthesia Care, Endoscopy, and Central Processing. Like all clinical programs, the Surgical Services Clinical Program's goal is to apply evidence-based best practices into our patient care delivery model.

Our 2010 Clinical Goal

Use our multi-disciplinary colon care process model to get shorter stays, fewer readmissions, and lower cost. Every year, Intermountain Healthcare treats about 900 patients who require colon resection surgery. Research shows that implementing a multidisciplinary care process model improves the quality of care and shortens a patient's stay in the hospital without increasing readmissions or return-to-surgery rates. So, in 2007, our general surgery development team created the multidisciplinary colon care process model (MDCS), which focuses on care protocols designed to return the patient's bowel functions back to normal as quickly as possible. The results of the MDCS are impressive, with approximately a 40% reduction in length of stay and costs, a decrease in the readmission rate, and decreased return to surgery.

Patient safety. System-wide efforts to help keep patients safe include:

• Universal Protocol, created in 2004 to address wrong site, wrong procedure, and wrong person surgeries in Joint Commission-accredited organizations nationwide, is among the National Patient Safety Goals. Intermountain implemented the three principal components of Universal Protocol across the system in 2005, which include: conducting a pre-procedure verification process; marking the procedure site; and performing a time-out before the start of the procedure. While not yet perfect, we have seen steady improvement in catching and preventing errors-and we continue to closely monitor and report compliance to this protocol.
• Surgical Care Improvement Project (SCIP). This is just one of several initiatives focused on improving patients' surgical outcomes by reducing the number of surgical site infections. Intermountain has made significant progress in implementing these strategies since their inception in 2006.

Surgical Care Improvement Project

Baseline 2006 compared to YTD 2010

• Nurse-administered sedation. In 2007, Intermountain recognized the potential for error in administering sedative medications, and the Surgical Services Clinical Program developed and implemented a comprehensive education program for nursing that would cast a safety net around this necessary activity.

Through system coordination, data analysis, and advanced reporting tools, Intermountain's Surgical Services Clinical Program will continue to improve the delivery of evidence-based, high-quality surgical care at the lowest appropriate cost. Through the work of this clinical program, Intermountain will continue to ensure that physicians and staff have the necessary information to make the most appropriate decisions for our surgical patients.