Quality Improvement in the DoS is managed across the different hospitals, including The Ottawa Hospital, CHEO, and Heart Institute.
At TOH, each division is committed to a mandate that aligns with the hospital’s vision around quality. The deliverables for each division are the following:
A multidisciplinary team (i.e., CUSP team) that meets on a regular basis with the aim of reviewing any quality or patient safety issues and creating plans to address these
Regular morbidity and mortality rounds following a standardized format with action items that are fed back to division members
Review of events from the patient safety learning system (PSLS) and ensuring that these events are reviewed and if required create action items to resolve issues identified
A minimum of one patient experience initiative
At CHEO, the PNSQIP programme has been running since June 2016. In the last 3 years, our SSI rate was significantly reduced, with the last report showing that we were exemplary on overall and abdominal surgery related sepsis, overall morbidity, as well as rate of surgery related transfusion.
At the Heart Institute, the Division of Cardiac Surgery recognizes the critical importance of monitoring and reporting quality indicators as a measure of its performance in the delivery of care to our patients.
Current Quality Initiatives in the DoS
At TOH,our department is recognized provincially and nationally as a leader in surgical quality. We play a prominent role in the provincial NSQIP collaborative and have run workshops in CUSP for both the Ontario and British Columbia collaborative. Our QI initiatives have been presented at provincial, national and international meetings. Of note, Health Quality Ontario looked to Ottawa to evaluate cost effectiveness of QI initiatives, such as CUSP. The engagement of surgical staff along with nurses, allied health care professionals and hospital administration has been vital to the success of our QI program. There is always a need for continuous improvement in QI, and therefore your contributions make a big difference to patient care.
Surgeon empathy scores were distributed to all surgeons and divisions to let them know where they are on the continuum. Importantly, surgeon feedback overwhelmingly found this to be a useful exercise and relevant to their practices. As far as we can tell, no other DoS has used this validated tool to look at surgeon empathy. We believe that this work has laid the foundation to broaden the project scope to include other departments and the provincial perspective. Health Ontario has expressed interest in disseminating to the 48-hospital collaborative.
With respect to the opioid reduction program, the consensus in the DoS (especially among residents) is that there is a cultural shift since the program launch, which began with a presentation at grand rounds last year. Multiple divisions are participating, and there is a collaborative TOHAMO grant proposal from Surgery and Anesthesia to accurately track data. Urology has completed a manual search and found a large change in their opioid prescribing behaviour, which they will be publishing on. We are helping to lead this initiative in Ontario. Provincially, there are 7 million fewer opioid pills in people's hands 6 months after provincially implementing this intervention. General Surgery has also recently reported on their opioid reduction results and have shown a significant decrease in the number prescribed.
A new initiative is the DoS carbon footprint program. To start, we are encouraging telemedicine across all divisions. In addition to reducing the departmental carbon footprint, the added benefits to this initiative alone include better patient experience, better access to surgeons, and less expense. Other target areas are reduced paper use (including pathology reports, which are still faxed) and coordination with the new Green Corporate Committee led by Joanne Read (where the DoS is currently the only major clinical department with a unified approach). More recently, we made significant strides implementing RightFax and are hoping to roll out across the department.
At TOH, excellence in patient care is the priority. By improving wait times, patients’ rating of experience and other key measures of a high-performing hospital, the goal is to rank among the top 10 percent of North American hospitals in providing safe, high-quality care to our patients. Numerous performance measurements are monitored, all aligning to TOH strategic directions, and these include the broad categories of finance, quality, people, partners, and academics.
SSI Rates: This is the first time we have been below the NSQIP expected average for SSI.
The most recent mortality numbers are likely reflective of a low number of data points, so may be a bit misleading over this relatively short scorecard period. Over the course of a full year, TOH tends to do well on this metric.
We may have a new TOH scorecard soon, so watch for more information from the QI Committee.
At CHEO, we have been working the following initiatives:
We have reviewed, standardized, and developed the perioperative normothermia guidelines.
With the help of NSQIP and the Solution for Patient Safety, we have maintained the adherence to the surgical site infection (SSI) bundle with good success.
CHEO Surgery is also developing its own perioperative QI program, which is in its infancy due to COVID.
We are exploring new ways to increase adherence to new standardized discharge information for patients and their families and developed information leaflets about analgesia and opioid use after surgical procedures.
We have designed a surgical site infection dashboard in EPIC, which shows CHEO on monthly basis compliance with the bundle elements introduced at CHEO.
We are in the fourth year since PNSQIP has been rolled out at CHEO. We are following diligently QI markers, such as surgical site infection and sepsis.
For more information, please contact the PNSQIP Surgeon Champion.
At Heart Institute, the Division of Cardiac Surgery has been working the following initiatives:
The Canadian Institute for Health Information (CIHI) in collaboration with the Canadian Cardiovascular Society (CCS) regularly publishes a national Cardiac Care Indicators Report, which includes all centres performing heart surgery in Canada. The August 2020 report included the following, and it showed the Division of Cardiac Surgery was a high performer for all three indicators.:
risk-adjusted mortality rates for isolated CABG
combined CABG with AVR
The Division with the support of the Heart Institute has recently undertaken a major initiative to strengthen our commitment to quality improvement when it began enrolling patients in the Society of Thoracic Surgeons (STS) Cardiac Surgery Database. Based in the US and established in 1989 this is an international quality and patient safety initiative with more than 1,100 participating hospitals in 11 countries around the world. Currently, it houses data on more than 6 million heart operations. Data from the STS data database are reported back to participant hospitals to facilitate comparisons to aggregate. Participating in this database will therefore allow the Division to benchmark itself against major centers around the world, such as the Cleveland Clinic. The STS database is widely regarded as the most comprehensive quality database in the world and our Division is unique in Canada in having committed significant resources to partake in it.
As part of this initiative the Heart Institute has purchased and supports the Patient Analysis and Tracking System (PATS) software for the Division. This allows the Division to manage its own STS data and to monitor, track and analyze the same data that is submitted to the STS. Using this software major morbidity and mortality are reported monthly, and it forms the basis of the annual report to the Quality of Care Committee (QOCC) of the Heart Institute.
In addition to the above, every cardiac surgery death is reviewed independently by Cardiac Surgery and Cardiac Anesthesia / Critical Care, and morbidity and mortality rounds are held on a regular basis with staff and residents.
For more information, please contact the Quality Assurance Lead in the Division of Cardiac Surgery.