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What does WellStar Cobb Hospital have in common with prestigious Beth Israel Medical Center in New York and Stanford Hospital in California? All three are part of an elite list of only 37 facilities worldwide that recently achieved meritorious status for surgical patient outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®).

Cobb is the only hospital in Georgia on the list, which represents the top 10 percent of participating hospitals. The hospitals were deemed meritorious with regard to their quality composite score in these outcome areas for all surgery cases:

  • Mortality
  • Deep vein thrombosis/pulmonary embolism
  • Cardiac incidents
  • Respiratory (pneumonia)
  • Unplanned intubation
  • Ventilator greater than 48 hours
  • Renal failure
  • Surgical site infection (SSI)
  • Urinary tract infection
“It’s amazing to see little Cobb Hospital in Austell listed with all these big names,” marveled Lynn Maltby, Cobb’s director of Surgery.

“We are very proud of this commendation,” said Stephen Odom, M.D., chair, Surgery Service Line Safety and Quality Committee, and a surgeon at WellStar Medical Group Surgical Specialists at Cobb. “The key will be to do the hard work to stay on the list year after year.”

All WellStar Hospitals Aiming for Meritorious List
Bill Mayfield, M.D., WellStar’s chief surgical officer, has championed WellStar’s systemwide participation in the ACS NSQIP. The Surgical Services service line and its Safety and Quality Committee have worked diligently with each hospital to improve surgical outcomes. Cobb’s impressive distinction is a big win.

“I have no doubt that all our hospitals will eventually earn the same commendation,” said Dr. Odom.

“We’re changing our culture,” says Dr. Mayfield. “We have great physicians and nurses, now it’s a matter of creating great processes to match. And it’s a team effort – it’s not just what happens in the operating room. Good outcomes are a result of all the components of patient care – from preparing the patient properly to patient education at discharge.”

For more than two years, WellStar has been part of the clinical outcomes database administered by the ACS. “This is meaningful data, based on a patient’s experience in the hospital – much different than claims data based on billing and discharge coding,” explained Dr. Mayfield.

A Cobb Case Study: SSIs
WellStar is using the data to identify areas for improvement. At Cobb, for example, one focus area was SSIs. In September 2011, Susan Franklin, RN, infection preventionist, began working on initiatives to reduce SSIs and her research was used to develop standards and initiatives.

“We also used the inpatient surveillance data for SSIs and reviewed our quality compliance with the Surgical Care Improvement Project (SCIP) core measures,” said Maryhelen Master, RN, core measure specialist for SCIP and team leader for Cobb’s SSI team. “The team then started focusing not only on quality compliance, but also on surgical practice.”

Led by Thomas McNamara, M.D., vice president of Medical Affairs, Cobb’s SSI team is comprised of team members from surgical leadership, performance improvement, education, infection prevention, anesthesia, pharmacy and core measures. The team meets monthly and members have defined roles, responsibilities, assignments and deadlines.

By January 2012, the team began implementing scientifically documented improvements such as:
  • Using chrorhexidine and alcohol as the preferred skin antiseptic agent
  • Avoiding hair clipping unless necessary; if hair is clipped, it is done in the pre-operative area
  • Performing bedside blood glucose monitoring during the entire operative process (pre-, intra- and post-op) for diabetes patients
  • Redosing preoperative antimicrobials as necessary
  • Providing antismoking education for smokers during preadmission testing
  • Maintaining the patient’s body temperature above 36 degrees C throughout the operative process


Success and National Acclaim
These improvements, along with many others throughout the patient experience, helped dramatically decrease the rate of SSIs: For colon surgeries, the rate dropped from 10.9 in FY 2012 to 1.3 in FY 2013; for hysterectomies, the rate went from 3.3 to 1.3.

Because Cobb’s SSI rate declined so significantly, Premier Hospital Engagement Network invited the SSI team to present at the National Premier Breakthroughs Conference in San Antonio, Texas, last summer. The conference hosts more than 4,000 participants from 1,000 organizations. Seven team members gave an overview of Cobb’s SSI process improvement, then fielded questions from the audience.

“It’s been amazing and very gratifying to work with such a great group of people – everyone involved was committed to making this happen for our patients,” said Franklin. “We’ve heightened awareness among surgeons, anesthesiologists, OR staff and nurses.”

The Science of Change
Dr. Odom helped lead Cobb on its journey of improving quality and safety.

“As a System, we realized we needed to change our culture to one of 200 percent accountability,” he said. “We mandated ongoing safety culture training for each staff member, which will be repeated every two years.”

The training introduced many evidence-based changes. Was this hard for team members to accept?

“Change is difficult for everyone,” said Odom. “There was some hand wringing. But when we could show surgeons, who are very competitive, the strong evidence that, for example, changing skin prep techniques lowered SSI risk, they got on board – moving from resistance to acknowledgment, then acceptance and finally, hardwiring these practices.”

Dr. Odom said Cobb’s process changes have positively affected all nine outcome areas examined by the ACS NSQIP, and that they all have a trickledown effect. “When Environmental Services cleans appropriately, patients don’t get infections from patients previously in the room; when we hydrate patients as we should before surgery, they are less likely to have renal issues; when we get the Foley catheter out in a timely manner, the risk of UTIs lessens.

“We’ve learned so much and will keep looking for ways to improve outcomes for our patients.”

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