Surgical Care Improvement Project (SCIP)

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Identified Participant Group

Ohio KePRO was one of two Quality Improvement Organizations (QIO) awarded a pilot project contract by the Centers for Medicare & Medicaid Services (CMS) in September 2003. Lessons learned from this pilot project have been utilized to facilitate a national approach as the new measures are incorporated into the 8th Statement of Work (SOW), which runs from August 1, 2005 through July 31, 2008.

About the SCIP Project
The national goal of SCIP is to reduce the morbidity and mortality associated with major surgical procedures by 25% over 5 years. Cooperation and collaboration of a wide variety of healthcare organizations and professionals are needed to reach this goal.

The SCIP quality improvement efforts will focus on reducing perioperative complications in four broad areas:

• Infection: Prevention of surgical site infections by the implementation of best practices recommended
  by the expert panel. Areas to be measured include administration of appropriate and on-time prophylactic
  antibiotics, which are discontinued within 24 hours post-op. Other measures include appropriate surgical
  site hair removal, normothermia, and glucose control during the perioperative period.
• Cardiovascular: Prevention of acute myocardial infarction through cardiovascular risk assessment
  prior to surgery and appropriate administration of beta-blockers. Measurement will include delivery of
  perioperative and prophylactic beta-blocker therapy.
• Respiratory: Prevention of ventilator-associated pneumonia (VAP) by using recommended practices in
  the ICU for post-surgical patients. Measurements will include (in the absence of contraindications),
  elevation of the head of the bed, peptic ulcer disease (PUD) prophylaxis, and appropriate weaning protocols.
• Thromboembolism: Prevention of venous thromboembolism (VTE) following surgery through the use of
  recommended pharmacological and mechanical prophylaxis. Measures will include use of recommended
  prophylaxis and the appropriate use of that prophylaxis.

National Steering Committee that offers guidance and expertise to the SCIP project

• American Hospital Association (AHA)
• American College of Surgeons (ACS)
• American Society of Anesthesiologists (ASA)
• Association of periOperative Registered Nurses (AON)
• Institute for Healthcare Improvement (IHI)
• Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• Department of Veterans Affairs (VA)
• Centers for Disease Control and Prevention (CDC)
• Centers for Medicare & Medicaid Services (CMS)
• Agency for Healthcare Research and Quality (AHRQ)

Benefits of Participating
Participating in the SCIP project is an opportunity to:

• Enhance your hospital's reputation in the community by being able to show significant and verifiable
  improvement in quality care
• Work collaboratively with your medical staff on improving care
• Be recognized as an early adopter and leader of quality improvement standards
• Learn and adopt new quality improvement methodologies that will satisfy future accreditation
  requirements
• Provide networking opportunities to learn about best practices from peers
• Receive relevant regular quarterly data
• Recruit and retain the best professionals possible
• Focus care for surgical patients on the evidence-based practices that improve patient outcomes

Additional benefits:

• Access to resources and successful interventions
• Technical and data collection support
• Access to national benchmarking data
• Tools to help you communicate with your community
• National recognition as an official SCIP participant

Although all Ohio hospitals are encouraged to begin addressing the best perioperative practices

recommended in SCIP, 15 to 20 hospitals, that perform at least 300 inpatient surgeries per year,

will participate in the SCIP IPG. The goal of the IPG is that 50% of the participants must achieve a

25% reduction in failure rate on 13 SCIP process measures. Abstraction will begin January 1, 2006.

The baseline consists of discharges from January 1, 2006 through June 30, 2006.

What Participation Involves

Hospitals will be asked to:

• Form a multidisciplinary SCIP team(i.e. surgeons, anesthesiologists, hospitalists, respiratory care
  practitioners, quality improvement experts, Pharmacists, financial staff, IT, etc.)
• Abstract files using the provided data abstraction tool and submit abstracted data for analysis to the
  CMS clinical warehouse. When alignment with JCAHO and the vendors is complete, your vendor may
  begin submitting the SCIP data
• Conduct team meetings on a regular basis
• Develop overall action plan and timeline
• Share progress, barriers and successes
• Strategize to incorporate a variety of improvement methods
• Meet with your Ohio KePRO Project Leader once a month
• Demonstrate commitment through signature of the CEO
• Help identify physician or other clinical champions
• Facilitate improvement on statewide goals (see below)

What Ohio KePRO will do for IPG Hospitals

• Facilitate improvement on statewide goals (see below)
• Provide:
  - Monthly on-site visits, preferably at time of SCIP team meeting
  - A project manual outlining all aspects of the project
  - Education and training on the data collection tools
  - Technical assistance for data collection
  - Individual consultation and education in QI methodology, specifically as it relates to rapid cycle
  testing of change and improvement
  - Regular teleconferences with academic resources

Statewide Hospital Quality Improvement Goals

Ohio KePRO will work with all Ohio hospitals toward improvement in the following areas:

• Increase the number of hospitals reporting the expanded set of twenty-two (22) quality measures
  for the Hospital Quality Alliance
• Increase the number of hospitals achieving a passing score (80% accuracy) on data validation
• Improve performance measure results on SCIP-1, prophylactic antibiotic received within one hour
  of surgical incision.
• Increase the number of critical access reporting hospitals by fifty percent (50%)