Quality Improvement
Mission Statement
Our mission is to continuously enhance the quality of care we provide, prioritizing patient-centered outcomes and ensuring safety and excellence in every aspect of our care. We are dedicated to improving the patient experience, supporting the well-being of our surgeons, residents, and staff, and maintaining the financial sustainability of our practices.
Current Projects
Safety & Quality
Department of Surgery Complications Reporting
PROCESS: Develop a process for self-reported complications reporting across the Department of Surgery by the end of FY25
OUTCOME: Achieve >30% complication capture between AHRQ PSI-9 & PSI-13 and self-reported complications by the end of FY25
Patient Experience
LTRCP & ACES Attestation
• Sustain LRTCP FY 24 performance within 95% confidence interval
• >25% established providers and 100% of new providers to complete ACES
Financial Strength
TEAM Model & Improving OR Scheduling Efficiency (Year 2)
TEAM Model PROCESS: Regular meetings (virtual or in-person) with the Accountable Care Team and other clinical and operational stakeholders to identify the scope of the CMS TEAM bundle(s) and opportunities for improvement, create a current-state process map, and build consensus with all stakeholders on a future-state process map for CMS TEAM.
TEAM Model OUTCOME: By the end of FY25, clinical teams will collaborate with Accountable Care leadership, inclusive of quarterly progress reviews, to develop a CMS TEAM model clinical pathway supported by clinical and operational stakeholders, that encompasses preoperative risk assessment/optimization, inpatient care, and 30 days postsurgical care.
Year 2: Reduce unused viable block time from an average of 39.9 hours to 30 hours by the end of FY25
Wellness
Improving Closed-Loop Communication
• Attestation to Wellness domain guidelines
• Identify baseline perceptions of communication quality and increase closed-loop communication in Gen 1 for high-impact OR events from X to Y and A to Z, respectively, by the end of FY25.
FY25 Focus Areas
LOS & Readmissions
LOS PROCESS: Integrate preoperative case management in colorectal, HPB, and surgical oncology by the end of FY25.
LOS OUTCOME: Reduce preoperative LOS in patients undergoing lap chole from a median of 2.7 days to 2.0 days, and reduce LOS in NSTI patients admitted to trauma surgery from a median of 32.3 days to 29 days, by the end of FY25.
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READMISSIONS PROCESS: Standardize discharge instructions for all high-utilization languages and increase utilization from X to Y by the end of FY25.
READMISSIONS OUTCOME: Reduce Division of General Surgery readmission rates from 10.3% to 9.7% or below by the end of FY25.
In The News
– SurgeryDossabhoy et al Receive SHC QPI Award
The project “Reducing Hospital Length of Stay after Carotid Endarterectomy and Endovascular Aneurysm Repair has been selected as the inaugural winner of Stanford Health Care's Quality & Performance Improvement (QPI) Award.
– SurgeryTeam Reduces Reimbursement Rejections by A Third
A team comprised of Linda Thomas, Co-Lead Carmen LoCascio as well as Robin Cohen, Amos Lam, Kevin Lee, Ana Mezynski, and Jackie Stahl participated in SHC's RITE (Realizing Improvement through Team Empowerment) Program and successfully reduced reimbursement rejections from 25 to 17%.
– SurgeryExploring the Impact of Resident-led Safety Council on Patient Care
As a co-chair of the Resident Safety Council (RSC) alongside Pediatric Resident Dr. Katherine Xiong, Dr. Garrison Carlos had a vision to elevate safety standards and foster a culture of continuous improvement. Over the last two years, they spearheaded four distinct quality improvement initiatives.
– Stanford Medicine MagazineInitiatives aim to make the operating room sustainable
Surgeons and anesthesiologists don’t want their jobs to harm the environment. They’re learning how to reduce, reuse and recycle in the OR.
