Surgical Care Improvement Project Pilot:
Barriers, Successes, and Lessons Learned

Ohio KePRO, working with the Oklahoma Foundation for Medical

Quality (OFMQ), is nearing completion of a two-year Special Pilot

Contract with the Centers for Medicare & Medicaid Ser vices

(CMS). By now many of you have probably heard of the Surgical

Care Improvement Project (SCIP) that will replace the Surgical

Infection Prevention (SIP) Project for the CMS 8th Statement of

Work, which begins on August 1, 2005.

   CIP is a national quality
   partnership of organi-
   zations committed to
improving the safety of
surgical care through the
reduction of postoperative
complications. The ultimate
goal of the partnership is
to reduce the incidence
of surgical complications
nationally by 25 percent by
the year 2010. The charge
of the Pilot Project and
the Quality Improvement
Organizations (QIOs) such as
Ohio KePRO is to determine
the feasibility of hospitals
collecting the data and, based
on those results, initiating
process improvement
activities to improve surgical
outcomes.

S

The Ohio KePRO and OFMQ
SCIP pilot team has been
working closely with eight
hospitals in Ohio and eight
in Oklahoma to determine
this feasibility since late
2003. The team's findings
are reported to the SCIP
Steering Committee whose

During the pilot, feedback
from the hospital staff has
been carefully documented
in the project diary, and a
summary report was delivered
to the Steering Committee
at the ACS National
Headquarters in Chicago on
April 28, 2005. The follow-
ing is a synopsis of some of
the findings, with the hope
that this information will
pave the way for hospitals
seeking to initiate quality
improvements in the surgical
arena.

members include the CMS,
the Centers for Disease
Control and Prevention
(CDC), the American
Hospital Association (AHA),
the American College
of Surgeons (ACS), the
American Society of
Anesthesiologists (ASA),
the Department of
Veterans Affairs (VA), the
Association of periOperative
Registered Nurses (AORN),
the Agency for Healthcare
Research and Quality
(AHRQ), the Institute for

  Frequent on-site visits by QIOs
 establish a partnership with QI
    personnel and encourage
involvement of others in the hospital.

Healthcare Improvement
(IHI), and the Joint
Commission on Accreditation
of Healthcare Organizations
(JCAHO).

Barriers
· Nearly all hospitals cite
 a lack of resources as a
 major barrier to partici-
 pation in the pilot.
· Quality Improvement (QI)

·

·

·

·

staff who don't have the
support of administrative
and physician staffs face
a daunting task when
collecting data and
especially when initiating
process changes.
Although the QIOs present
various teleconferences and
seminars to encourage
sharing of information
among the pilot hospitals, it
is a burden on the hospital
staff to take time out to
participate.
Initially there was a nearly
universal challenge in
obtaining physician buy-in,
but as the pilot progresses
the QIOs are able to
support the physicians
who want to learn more.
Keeping up-to-date with
known best practices and
the most current evidence
base is a huge barrier for
physicians and other clinical
staff.
When the hospital QI
department is the only one
involved in the project,
the burden of data

2

 abstraction is so time-intensive that little time is left for
 interventions.
· Because most hospitals collect data for several projects,
 the burden of double data entry proves to be a significant
 issue. This information was stressed to the members of
 the Steering Committee.
· Often there is no clear assignment regarding the
responsibility for ordering beta blockers or managing
perioperative glucose control during the perioperative
period.

Keeping up-to-date with known best
 practices and the most current
evidence base is a huge barrier for
physicians and other clinical staff.

Successes
· A recruitment brochure delineating benefits of participation
 sparks interest and is an easy-to-share summary of the
project.
· One hospital received a grant from the Hospital
 Foundation to fund participation in the pilot.
· The pilot Web site, www.scippilot.com, provides a way for
 hospitals to communicate with the QIO and is a source
 for manuals, literature, sample protocols, upcoming
 events, and the most current information.
· Monthly teleconferences promote educational topics and
 hospital sharing.
· Hospitals with monthly visits by QIO staff are more successful
 in identifying areas for improvement and initiating change.
· Three one-day seminars give hospital staff a chance to
 learn, network, and share with other hospitals.
· Hospitals with multidisciplinary SCIP teams, including
 QI, Infection Control, Pharmacy, Operating Room (OR)
 and physicians, are more likely to move beyond data
 abstraction to process improvements.
· Hospitals where the pharmacist is the "gatekeeper" are
 less likely to have prophylactic antibiotics given for
 longer than the recommended time.
· The QIOs provided a Change Package, based on the
 results from the pilot, which tracks a patient's progress
 from admission to discharge, highlights the best time for
 interventions, and gives examples of possible process
 improvements.
· The QIOs provided Clinician Manuals for each of the
 modules (Infection Prevention, Respiratory Complication
 Prevention, Cardiac Complication Prevention, and
 Venous Thromboembolism Prevention) as a resource for
 physicians and other clinical staff.
· Changes were made in preprinted orders, documentation
 records, and protocols to increase the clinicians' opportunity
 to make the right choice.
· Some anesthesiology departments took ownership of
 starting the pre-op prophylactic antibiotic and maintaining
 glucose control during surgery.
· Razors were eliminated from the OR to facilitate appropriate
 surgical site hair removal.
· Some hospitals use Bair Huggers, caps on patients, and
 raising the temperature in the OR to maintain perioperative
 normothermia.

Lessons Learned
· Buy-in on all levels, including hospital administration,
 physicians, and clinical staff is required if the project is
 to be successful.
· Ongoing follow-up and support by the QIO increases the
 likelihood of ongoing abstraction and participation.
· The pilot Web site is a valuable resource for hospitals and
 will be replaced by the National SCIP Web site at
 www.medqic.org/scip.
· Participation on the pilot e-mail exchange, scipx-
 change@yahoogroups.com, gives hospitals an opportunity
 to share and ask questions of other hospitals.
· Frequent on-site visits by QIOs establish a partnership
 with QI personnel and encourage involvement of others
 in the hospital.
· Face to face meetings between QIO and hospital pilot
 staffs encourages interaction and sharing among hospitals.
· Prepared materials and agendas keep project and abstraction
 tool training on target.
· Pilot hospital staff suggest the following topics for educational
 opportunities:
     I Beta blocker use and glucose control in noncardiac
    surgery
     I Appropriate venous thromboembolism prophylaxis

    Legal issues regarding use of evidence-based medicine
    in discontinuing prophylactic antibiotics
· Pilot hospitals provide valuable feedback on all aspects of
 the project. It is important to listen to their comments
 and suggestions, as they are the front line in any quality
 improvement endeavor.

I

For more information on SCIP, please contact the Acute
Care Services Team at 1-800-385-5080; e-mail:
hospital@ohqio.sdps.org. or lmistovich@ohqio.sdps.org I

3

Hospital Culture a Key to Nurse
Recruitment and Retention

Quality healthcare is dependent on many things including dedicated healthcare providers, commitment

to the use of evidence-based practices, healthy finances, and an organizational culture that fosters

excellence. It is difficult to imagine quality healthcare without these components. Attracting and retaining

dedicated healthcare providers is a major challenge to hospitals as well as long-term care facilities and

home health agencies.

In 2004, the RN shortage in Ohio was just under six percent.
This is a significant improvement from 2002 when the shortage
was almost 11 percent. Ohio is projected to have a 29 percent
shortage by the year 2020. Those who are interested in
entering nursing programs are often turned away due to a
shortage of nursing faculty. The challenges of solving the
nursing shortage are multifaceted and require a collaborative
effort between healthcare institutions, educational institutions,
and legislators, as well as experienced nurses who can mentor
and encourage young adults to enter the nursing profession.

    rganizational culture has a significant impact on a hospital's
    ability to attract and retain quality healthcare providers
    of all professions--physicians, nurses, respiratory care
practitioners, social workers, and so on. Senior leaders are
in a unique position to introduce, nurture, and monitor this
culture to ensure it is one in which professionals are valued
and rewarded for providing quality patient care.

O

Nursing shor tage
The Bureau of Labor Statistics reports that the largest job
growth in healthcare between 2002 and 2012 will occur in
the Registered Nurse (RN) profession. As of last year, there
were 126,000 RN vacancies in the nation's hospitals.
Compounding this issue are the large numbers of nurses
retiring within the next 10 years and fewer people enrolling
in nursing programs.

 Senior leaders are in a unique
position to introduce, nurture, and
  monitor a hospital's culture.

Magnet designation
Magnet designation is currently the most popular method of
attracting and retaining nurses. It is the gold standard for
measuring quality nursing practice. Seven hospitals in Ohio
have received Magnet designation and many more are actively
pursuing this recognition. Those currently designated are
Cleveland Clinic Foundation, Columbus Children's Hospital,
Miami Valley Hospital, The Ohio State University Hospitals,
St. Joseph Health Center of Humility of Mary Health
Partners, St. Elizabeth Health Center of Humility of Mary
Health Partners, and Upper Valley Medical Center.

The Magnet Recognition Program ^® was developed by the
American Nurses Credentialing Center, a subsidiary of the
American Nurses Association, to recognize the best in pro-
fessional nursing practice. Criteria are based on the Scope
and Standards for Nurse Administrators, which delineates
methods of building and sustaining programs of nursing
excellence. Begun by a study of the American Academy of
Nurses in 1983, the initial Magnet research identified and
described variables called the "forces of magnetism" that, when
present, seemed to attract and retain well-qualified nurses.

The evaluation process is extensive and costly--as much as
$50,000 or more for large institutions. Potential benefits include
the enhancement of recruitment and retention, improvement
of quality outcomes, and the increase in utilization by consumers
and healthcare plans. Organizations must reapply every
four years.

Characteristics of Magnet hospitals that address organizational
culture can be achieved with or without Magnet designation.

4

Significant attributes of these organizations include an
environment that supports professional nursing practice, the
availability of experienced and advanced practice nurses,
collaborative working relationships within the profession as
well as between professional groups, and a commitment to
excellence and innovation in patient care.

Finding creative solutions
Ohio hospitals are doing much to address the anticipated
nursing shortage. Vacancy rates for RNs in Ohio are
currently at 4.8%. FutureThink is an initiative with
the backing of more than 300 nurse executives, nurse
educators, staff nurses, administrators and CEOs
developed by the Ohio Organization of Nurse Executives
and the Ohio Hospital Association's Jean Scholz, Director
of Health Policy. The goal of the initiative is to create a
better future for delivery of healthcare, thereby creating
lasting changes to strengthen recruitment and
retention of nurses. One strategy is to partner with
businesses and educational institutions to identify
innovative solutions.

To learn more about what Ohio hospitals are doing
to recruit and retain nurses, please visit the Ohio
Hospital Association Web site at
http://www.ohanet.org/workforce and follow links
to FutureThink, the Hospital Workforce Forum,
and other related sections. I

Hospital Staff Rosters Due to Ohio KePRO
by August 1, 2005

Hospitals are required under Medicare Conditions of
Participation to obtain a physician acknowledgment statement.
This statement must be signed and dated at the time the
physician is granted admitting privileges or admits his or her
first patient to the hospital. Since hospital reimbursement
is based in part on the diagnoses and procedures documented
by the physician, the physician attests in the statement
that he or she will document this information accurately.
The statement also outlines the penalties for misrepresenting
this information.

In June, Ohio KePRO's Review Department mailed letters
to hospitals requesting they submit a staff roster of all
physicians (excluding radiologists, pathologists, and
anesthesiologists) who were granted admitting privileges
during the period from May 1, 2004 through April 30, 2005.
The roster should include each physician's UPIN number,
address, phone number, and the date privileges were
granted.

The rosters are due to Ohio KePRO no later than
August 1, 2005. If you have any questions, please
contact the Review Department at 1-800-385-5080;
e-mail: review@ohqio.sdps.org. I

5

New Web Site Focuses on
Hospitals' Quality of Care

A new consumer Web site unveiled April 1, 2005, by the Centers

for Medicare & Medicaid Ser vices (CMS) and the Hospital Quality

Alliance, a public-private collaboration, provides instant, objective,

easy-to-use free information about the quality of hospital care in

Ohio and nationwide.

N

    early every major newspaper in
    Ohio and statewide radio and
television media reported on the launch
of hospital quality information now
available by visiting www.hospital
compare.hhs.gov or www.medicare.gov
and selecting Compare Hospitals
in Your Area, or by calling
1-800-MEDICARE (1-800-633-4227).
Either way, consumers get the infor-
mation they need to help them make
more informed healthcare decisions.

"CMS's new Web resource, Hospital
Compare, gives consumers information
to help them make an informed decision
about hospital care," said Gayle
Smith, CEO of Ohio KePRO, Ohio's
Medicare Quality Improvement
Organization. "We encourage consumers

to use this tool, talk with their physicians,
and consult other resources for hospital
information."

Repor ts on three conditions
Hospital Compare reports quality of
care information for hospitals about care
to all adult patients, regardless of payer,
on three common conditions: heart
attack, heart failure, and pneumonia.

Ohio KePRO is working with the Ohio
Hospital Association (OHA), which
             represents Ohio's
               170 hospitals and
                40 health systems,
                in support of this
                 voluntary quality
                  reporting tool as
                  a way to enhance

existing hospital quality initiatives and
educate consumers.

"Ohio's hospitals encourage patients
to take an active role in their health
care, and Hospital Compare is one
resource to help patients make vital
healthcare decisions," said James R.
Castle, OHA president and CEO.
"Patients should also talk to friends
and family, consult physicians, nurses
and other healthcare providers, and
check insurance coverage when
selecting a hospital."

Hospital Compare is also a compo-
nent of OHA's new Consumer's Guide
to Quality HealthCare in Ohio
resource at www.ohanet.org/portal/ that
connects Ohioans with a wide range of
information on the cost and quality of
healthcare in Ohio. The OHA site
provides information about a specific
hospital or physician, helps patients
find area healthcare providers with a
strong record of quality, and compares
charges for common treatments at
local hospitals.

Number one priority
"Providing quality care is the number
one priority for Ohio's hospitals,"
Castle said. "The availability of a
comprehensive quality resource on the
Web highlights hospitals' dedication to
keeping patients safe and informed."

6

Ohio KePRO Medical Director Alice Stollenwerk Petrulis,
MD, FACP, noted Ohio KePRO plays a pivotal role in
improving Ohio hospital quality by offering hands-on
resources and technical assistance, one-on-one training,
and staff education.

"As an organization in Ohio charged with working with hospitals
to improve their quality of care, we have seen firsthand
how hospitals are making changes and improving," said Dr.
Petrulis. "We commend our state's hospitals for making
quality a top priority every day."

Ohio KePRO also has available for consumers a step-by-step
guide to navigate Hospital Compare and a hospital "checklist"
for consumers to use when comparing other characteristics
of hospital care, such as facility accreditation and availability
of private rooms. Both of these printed resources are free

OhioHealth First
in the Nation to
Receive Award

OhioHealth has received the first-ever national
Award for Excellence in Medication-Use Safety.
Sponsored by the American Society of Health System
Pharmacists Research and Education Foundation,
this award honors a pharmacist-led multidisciplinary
team for significant institution-wide improvements in
medication safety.

Hospital Compare reports quality
of care information for all adult
patients, regardless of payer, on
 heart attack, heart failure,
       and pneumonia.

Hospitals in the Columbus-based OhioHealth system
include Riverside Methodist Hospital, Grant Medical
Center, Doctors Hospital, Southern Ohio Medical
Center, Hardin Memorial Hospital, Marion General
Hospital, Doctors Hospital-Nelsonville, and Grady
Memorial Hospital. I

Congratulations         

and can be ordered online through the Shopping Bag feature
of the Ohio KePRO Web site at www.ohiokepro.com/shopping
or through the Ohio KePRO Medicare Beneficiary Help Line
at 1-800-589-7337.

to all of you!           

Dr. Petrulis noted some hospitals may have data on
additional conditions, and in the future, new measures and
information on patients' perceptions of care will be added.

"People should review the data on Hospital Compare and
then talk with their physicians about any concerns and
about quality of care," Dr. Petrulis continued. "You cannot
always predict when you will need hospital care, but you
can be informed."

CMS's participation in Hospital Compare is part of its hospital
quality initiative, which in turn is part of a national Quality
Initiative that also focuses on improving the quality of care
in home health agencies and nursing homes. The national
Quality Initiative is an important step in CMS's comprehensive
quality strategy, which consists of four elements:

· Regulation and enforcement activities conducted by State
 Survey Agencies and CMS;
· Improved information for consumers on quality of care;
· Ongoing, community-based quality improvement
 programs for providers; and
· Collaboration and partnerships to leverage knowledge
 and resources. I

7

Medicare Adds
  Coverage of
 Smoking and
Other Tobacco
Use Cessation
    Ser vices

The Centers for Medicare & Medicaid Ser vices (CMS) recently announced it is

adding coverage for smoking and tobacco use cessation counseling for cer tain

beneficiaries that will help them quit the habit.

"C

       overing smoking
       and tobacco use
       cessation counseling
for seniors has great potential
to save and improve lives
for millions of seniors," said
CMS Administrator Mark B.
McClellan, MD, PhD. "This
is another step in turning

Medicare into a prevention-
oriented health program."

The coverage decision, which
was proposed for public
comment in December,
involves Medicare benefici-
aries who have an illness
caused or complicated by

Millions of Medicare beneficiaries
have smoked for many years, and
 are now experiencing the heart
problems, respiratory problems, and
many other often-fatal diseases
   that smoking can cause.

tobacco use, including heart
disease, cerebrovascular
disease, lung disease, weak
bones, blood clots, and
cataracts­the diseases that
account for the bulk of
Medicare spending today. It
also applies to beneficiaries
who take any of the many
medications whose effec-
tiveness is complicated by
tobacco use, including
insulins and medicines for
high blood pressure, blood
clots, and depression.

Public comments generally
supported the approach
CMS proposed, although
some commentators preferred
broader coverage of all
tobacco users. CMS modified

the proposal in response to
comments by removing a
requirement that providers
have uniform training in
smoking and tobacco use
cessation counseling, since
no nationally accepted
standards exist. When
standards do become
available, CMS plans to
consider whether to add
those requirements to its
coverage policy.

"Millions of Medicare
beneficiaries have smoked
for many years, and are
now experiencing the heart
problems, respiratory
problems, and many other
often-fatal diseases that
smoking can cause," Dr.

8

McClellan said. "It's really hard to quit, but we are going to
do everything we can to help. I especially want to urge
smokers on Medicare who are just starting to experience
heart problems or lung problems or high blood pressure to
take advantage of this new step."

440,000 die annually
The Centers for Disease Control and Prevention (CDC) has
estimated that 9.3 percent of Americans age 65 and older
smoke cigarettes. About 440,000 people die annually from
smoking-related disease, with 300,000 of those deaths in
those 65 and older. CDC estimated in 2002 that 57 percent
of smokers age 65 and over report a desire to quit. Currently,
about 10 percent of elderly smokers quit each year, with
1 percent relapsing.

"The evidence fully supports the hope that seniors with diseases
and health effects caused by smoking and tobacco use can
quit, given the right assistance," Dr. McClellan said.

The CMS decision to cover cessation counseling comes in
response to a June 2004 request from the Partnership for
Prevention (PFP). The PFP requested CMS open a National
Coverage Decision (NCD) to consider coverage of tobacco
cessation counseling as detailed in the U.S. Department of
Health and Human Services, Public Health Service (PHS)
2000 Clinical Practice Guideline: Treating Tobacco Use
and Dependence.

The U.S. Surgeon General has
reported that the benefits of
cessation do extend to quitting
       at older ages.

The PHS 2000 Guideline has been endorsed by many healthcare
and professional organizations. Based on the evidence
reflected in the guidelines, CMS had decided to extend

builds on a series of Department of Health and Human
Services (HHS) initiatives designed to help Americans quit
smoking, including the opening of a new national quitline
(1-800-QUITNOW) and designating all HHS campuses
tobacco-free.

Not too late to quit
While many may think that those who quit at age 65 or
older fail to reap the health benefits of abstinence from
tobacco, the U.S. Surgeon General has reported that the
benefits of cessation do extend to quitting at older ages.
Smoking cessation in older adults leads to significant risk
reduction and other health benefits, even in those who
have smoked for years.

Medicare's upcoming prescription drug benefit will cover
smoking cessation treatments prescribed by a physician.

Researchers estimate smoking accounts for approximately
10 percent of the total costs of the Medicare program or
about $20.5 billion in 1997. On average, nonsmokers survived
1.6-3.9 years longer than those who have never smoked.

smoking and tobacco use cessation coverage to Medicare
beneficiaries who smoke and have been diagnosed with a
smoking-related disease or are taking certain drugs whose
metabolism is affected by tobacco use. This announcement

9

Ohio KePRO to Accelerate
Quality Improvement in
Hospitals

Ohio KePRO, the Medicare Quality Improvement Organization (QIO) for Ohio, will begin working under a

new three-year contract with the Centers for Medicare & Medicaid Ser vices this August. The contract,

known as the 8th Statement of Work (8th SOW) calls on Ohio KePRO to accelerate quality improvement

in hospitals.

    hio KePRO's technical assistance
    will build on the growing
    commitment by hospitals to publicly
report their performance in areas critical
to improving patient safety. Ohio KePRO
will work intensively with groups of
hospitals, each representing about 15
percent of prospective payment system
(PPS) hospitals in Ohio that apply to
CMS for assistance. Ohio KePRO's
assistance will include:

O

· Working with a group of hospitals to
 improve their performance by 50
 percent on a composite of the 10
 publicly reported quality of care
 measures for heart attack, heart failure,
 and pneumonia.

· Working with a second group of
 hospitals to improve performance on

13 surgical care processes important
for preventing surgical infections,
cardiovascular complications, venous
thromboembolism, and ventilator-
associated pneumonia, and for safer
vascular access for dialysis. A major goal
will be to help these hospitals achieve
25 percent relative improvement
across the 13 measures.

· Helping a third group of hospitals adopt
 and use information technology such
 as computerized physician order
 entry systems, bar coding systems,
 or telehealth technology.

· Working to ensure that 95 percent of
 all hospitals in Ohio submit valid data
 for the 10 publicly reported measures;
 that 25 percent of PPS hospitals
 publicly report an expanded set of 22

quality measures for heart attack,
heart failure, pneumonia, and surgical
infection prevention; and that hospitals
statewide improve by 12 percent on
the first of the three SIP measures.
Also, Ohio KePRO will consult with the
management of a group of hospitals
to improve organizational culture
supporting patient safety.

· Helping to ensure that critical access
 hospitals (CAH) report data for
 a revised set of 12 CAH Quality
 Improvement Measures, and demon-
 strate improvement on at least one of
 these measures. Ohio KePRO will also
 work with a group of CAHs to assess
 and improve their organizational
 safety culture. I

10

save the dates!

Ohio KePRO's Quality Summits

Over the last three years, healthcare providers in Ohio earned national recognition
for quality care through working with Ohio KePRO on quality improvement projects.

J U LY 2 0 0 5

SMTWTFS

1

2

For the next three years, Ohio KePRO will focus on:
  I Promotion of improvement in clinical performance
   measure results.
  I Information technology systems adoption and use.
  I Effective redesign of care processes.
  I Changes in organizational culture.

3

4

5

678

9

10 11 12 13 14 15 16

17 18 19 20 21 22 23

The Ohio KePRO Quality Summit is designed to introduce providers to the
Quality Improvement Organization program and its projects to improve health
care in Ohio. Summit sessions include a general overview and breakout sessions
based on provider setting. There will be two repeating sessions per day, with
the morning session beginning at 8:30 a.m. and the afternoon session begin-
ning at 1:00 p.m.

24 25 26 27 28 29 30

Suggested attendees: CEOs/Senior Leaders, Physician Champions, Office
Managers, Quality Improvement Staff, Compliance Officers, and Clinicians.

Please join Ohio KePRO staff at a Quality Summit on one of the
following dates:

Ramada--Springdale
Dayton/Cincinnati

Embassy Suites--Independence
Cleveland

Please share this information with your staff.
To learn more, please contact the Acute Care Services Team
at 1-800-385-5080; e-mail: hospital@ohqio.sdps.org.

11

QUALITY IMPROVEMENT CALENDAR

August
  I Cataract Awareness Month
  I National Immunization Awareness Month

September
  I Prostate Cancer Awareness Week--12th ­18th
  I Healthy Aging Month
  I National Cholesterol Month
  I Prostate Health Month

October
  I National
  I National
  I National
  I National
  I National
  I National
  I National

Depression Screening Day--6th
Mammography Day--21st
Infection Control Week--17th ­21st
Respiratory Care Week--23rd ­29th
Breast Cancer Awareness Month
Brain Injury Awareness Month
Glaucoma Awareness Month

Acute Care Ser vices Team
David A. Bitonte, DO, MBA, FAOCA
Rita Bowling, RN, MSN, MBA, CPHQ
Meghan Harris, MS
Jennifer Bitterman, RHIA, MBA
Tracy Hammar, MBA
Dawn Knopp, RN, BSN, CPHQ
Lynn Mistovich RN
Donna Moore, RN, MBA, CPHQ
Patricia Nelson, RN
Diane Oye, RN, BA
Karl E. Peters
Rosann Pasko, MS
Liz Simpson
Barbara G. Stiebeling, RN, MSN
Mona D. Wendell, RN, BA, MBA

Medical Editor:
David A. Bitonte, DO, MBA, FAOCA

Executive Editor:
Suzana C. Iveljic, MBA

Editor :
Rober t A. Feigenbaum, MS

Associate Editor:
Barbara G. Stiebeling, RN, MSN

Publication No. 4020-OH-004-7/2005. This material was prepared by Ohio
KePRO, the Medicare Quality Improvement Organization for Ohio, under
contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The
contents presented do not necessarily reflect CMS policy.

T H E S U M M E R 2 0 0 5 I S S U E O F Q U A L I T Y M AT T E R S H A S A R R I V E D !
                A Newsletter for Acute Care Ser vices