What Was Done
Global Problem Addressed
Before 2020, there was a forum called the Surgical Quality and Safety Committee which met to address trends and surgical-based processes within the hospital. During the pandemic the Surgical Quality officer position was vacated, and the meeting was disbanded to focus on other needs. At the system level, a Surgical Quality and Safety Committee continued to address these issues in a global manner, however real time quality surgical review was lacking at the local level. In July 2022 the Quality team under new leadership began the review process of participating in the ACS Quality Verification Program. During this investigation process it was noted that a consistent review process for quality-based discussions and planning was lacking or occurring in silos which led to duplicate projects with competing goals. In 2023 we began actively building the hospital based SQSC.
Identification of Local Problem
The hospital does not have a consistent forum for review and discussion of quality based surgical care. The lack of transparency and leadership defining common goals affected all surgical related teams. The problem existed and was identified when we began the process for the Quality Verification Program Focused Review. The problem affects all surgical related units and teams, specifically we chose to start with one representative from all surgical teams, the lab, pharmacy, the risk team, the quality reviewers, PACU, anesthesia, the OR leadership, and the SICU.
How Was the Quality Improvement (QI) Activity Put in Place
Context of the QI Activity
Henry Ford Hospital is a not-for-profit, urban, designated Level I trauma center with helicopter service, tertiary quaternary care hospital located in Detroit, MI. With 877 licensed beds, Henry Ford has 646 inpatient beds, 39 Level III Neonatal ICU beds, 54 Observation beds, and 165 Adult ICU beds; the largest in Michigan. Henry Ford also offers an education, teaching, and research center located on a 53-acre campus in Detroit employing over 6,000 team members at the Henry Ford Hospital campus. Henry Ford Hospital is home of the Henry Ford Medical Group – a closed practice model of more than 1,900 physicians and researchers. The closed practice model resulted from a meeting Henry Ford had with Dr. William Mayo of the Mayo Clinic in 1915. All quality initiatives focus on improving patient outcomes and providing patients with a higher quality of care. The goal of the project was to improve communication which would streamline planning and quality initiatives. By reducing redundant practices, we could focus on more projects. Improved communication between specialties allowed for globally appropriate approaches versus maintaining the current silo-based approach. The project took about 6 months to launch and is currently running monthly.
Planning and Development Process
We created a space that did not exist for collaborative discussion and have met bimonthly since the initiation of the plan. This is achievable at our institution because our Surgical Quality Officer is very motivated and a strong leader. She leads by collaboration and motivates others to buy into the quality work. All our team members have a passion for providing the best care with a focus on quality improvement. Those leaders report back to their respective areas for information sharing and continuation of improvement projects. The creation of a collaborative meeting will allow patients to receive coordinated care. By focusing on reduced readmission rates, reduced return to operating room, and increased utilization of pre and post operative protocols, we will improve overall care of patients.
Description of the Quality Improvement Activity
Meetings were designed to take place bi-monthly at 6:30 am for 1 hour. Meeting prior to surgical start time would ideally allow most partners to attend without impacting our surgical patients. Our Surgical Quality Officer leads the meeting; initially we rotated between virtual and in person. As of June 2024, meetings were increased to monthly, and the location was changed to in person based on observation of natural workgroups forming when in person and feedback provided by staff. At our 1 year meeting we will celebrate the continued collaboration, and we will be polling the partners to see what updates or changes the group suggests moving forward. Stakeholder input was gathered throughout the process by direct and indirect means during the SQSC meetings, offering email follow up for delayed responses, and scheduling one-on-one meetings. The Surgical Quality Officer presented at grand rounds for different surgical services and encouraged continued collaborative work and follow up. We also set time aside after each presentation to ask for feedback or how we could create subgroups to further discuss ongoing quality projects.
