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  • Measure Summary
  • NQMC:009665
  • Mar 2014

Perioperative protocol: percentage of surgical cases where the baseline count was conducted prior to the patient arriving in the operating/procedure room.

Card R, Sawyer M, Degnan B, Harder K, Kemper J, Marshall M, Matteson M, Roemer R, Schuller-Bebus G, Swanson C, Stultz J, Sypura W, Terrell C, Varela N. Perioperative protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2014 Mar. 124 p. [124 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Danielson D, Bjork K, Card R, Foreman J, Harper C, Roemer R, Stultz J, Sypura W, Thompson S, Webb B. Preoperative evaluation. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jul. 61 p.

The measure developer reaffirmed the currency of this measure in January 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of surgical cases where the baseline count was conducted prior to the patient arriving in the operating/procedure room.

Rationale

The priority aim addressed by this measure is to improve the adherence of the key components of the perioperative protocol.

Evidence for Rationale

Card R, Sawyer M, Degnan B, Harder K, Kemper J, Marshall M, Matteson M, Roemer R, Schuller-Bebus G, Swanson C, Stultz J, Sypura W, Terrell C, Varela N. Perioperative protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2014 Mar. 124 p. [124 references]

Primary Health Components

Perioperative protocol; baseline count

Denominator Description

Total number of surgical cases (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients having a baseline count conducted and documented on the whiteboard prior to the patient arriving in the operating/procedure room (see the related "Numerator Inclusions/Exclusions" field)

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory Procedure/Imaging Center

Hospital Inpatient

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

All ages

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Staying Healthy

IOM Domain

Effectiveness

Safety

Case Finding Period

The time frame pertaining to data collection is monthly.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Total number of surgical cases

Population Definition: Patients of all ages who have a surgical procedure performed.

Data Collection: Retrospective collection of any measures associated with documentation can be done by randomly sampling charts of patient cases.

Concurrently, collection will need to be done through direct observation either by a quality/safety advocate or "secret shopper," someone who has a dual function on the team but whose observation and measurement function is not known.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of patients having a baseline count* conducted and documented on the whiteboard** prior to the patient arriving in the operating/procedure room

*Baseline Count: Conducted prior to the patient's arrival in the operating/procedure room to establish the initial record of countable items that might be used during the procedure.

**Whiteboard: A preformatted dry erase board or computer screen, directly viewable by the entire surgical team, should be used to document sponges/soft goods, sharps, miscellaneous item counts, and when possible, instrument counts. The ability of the entire team to view the count information and assist in the correct identification of tucked and unaccounted for items enhances safety and reduces the risk of errors.

Exclusions
Unspecified

Numerator Search Strategy

Institutionalization

Data Source

Paper medical record

Other

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Percentage of surgical cases where the baseline count was conducted prior to the patient arriving in the operating/procedure room.

Measure Collection Name

Perioperative Protocol

Submitter

Institute for Clinical Systems Improvement - Nonprofit Organization

Developer

Institute for Clinical Systems Improvement - Nonprofit Organization

Funding Source(s)

The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin.

Composition of the Group that Developed the Measure

Work Group Members: Randall Card, MD (Work Group Leader) (Cuyuna Regional Medical Center) (Family Medicine); Mark Sawyer, MD (Work Group Leader) (Mayo Clinic) (Trauma and Emergency Surgery); William Sypura, MD (Fairview Health Services) (Family Medicine); Mary Matteson, RN, BA (Gillette Children's Specialty Healthcare) (Surgery); Gwen E. Schuller-Bebus, RN, MA (Gillette Children's Specialty Healthcare) (Surgery); Cheryl Swanson (Gillette Children's Specialty Healthcare) (Patient Safety and Quality); Jerry Stultz, MD (HealthPartners Medical Group and Regions Hospital) (Pediatrics); Rebekah Roemer, PharmD, BCPS (Park Nicollet Health Services) (Pharmacy); Kathleen Harder, PhD (University of Minnesota) (Human Factors Content Consultant); Carrie Terrell, MD (University of Minnesota) (OB/GYN); Nicole Varela, MD (Winona Health) (Anesthesiology); Barb Degnan, RN, BSN (Patient Representative); Jill Kemper, MA (Institute for Clinical Systems Improvement [ICSI]) (Project Manager); Melissa Marshall, MBA (ICSI) (Project Manager)

Financial Disclosures/Other Potential Conflicts of Interest

The Institute for Clinical Systems Improvement (ICSI) has long had a policy of transparency in declaring potential conflicting and competing interests of all individuals who participate in the development, revision and approval of ICSI guidelines and protocols.

In 2010, the ICSI Conflict of Interest Review Committee was established by the Board of Directors to review all disclosures and make recommendations to the board when steps should be taken to mitigate potential conflicts of interest, including recommendations regarding removal of work group members. This committee has adopted the Institute of Medicine Conflict of Interest standards as outlined in the report Clinical Practice Guidelines We Can Trust (2011).

Where there are work group members with identified potential conflicts, these are disclosed and discussed at the initial work group meeting. These members are expected to recuse themselves from related discussions or authorship of related recommendations, as directed by the Conflict of Interest committee or requested by the work group.

The complete ICSI policy regarding Conflicts of Interest is available at the ICSI Web site External Web Site Policy.

Disclosure of Potential Conflicts of Interest

Randall Card, MD, FAAP – Work Group Leader
Family Medicine, Cuyuna Regional Medical Center
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Barb Degnan, RN, BSN – Work Group Member
Patient Representative, ICSI Patient Advisory Council
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Kathleen Harder, PhD – Work Group Member
Human Factors Content Consultant, University of Minnesota
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: ICSI Prevention of Unintentionally Retained Foreign Objects
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Mary Matteson, RN, BA – Work Group Member
Charge Nurse, OR Circulator/Scrub, Gillette Children's Specialty Healthcare
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Rebekah Roemer, PharmD, BCPS – Work Group Member
Pharmacy, Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Mark D. Sawyer, MD – Work Group Leader
Consultant, Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Gwen E. Schuller-Bebus, RN, MA – Work Group Member
Nurse Manager, Surgical & Peri Anesthesia Services, Gillette Children's Specialty Healthcare
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Jerry Stultz, MD – Work Group Member
Pediatrics, Health Partners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Reviewed image charts for TREC Med information retrieval project through Oregon Health and Science University

Cheryl Swanson – Work Group Member
Clinical Facilitator, Patient Safety and Quality, Gillette Children's Specialty Healthcare
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

William Sypura, MD – Work Group Member
Family Medicine, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Carrie Terrell, MD – Work Group Member
Assistant Professor, Chief of Staff UMMC, Medical Director WHS, University of Minnesota
National, Regional, Local Committee Affiliations: University of Minnesota Physicians Board Member, MN ACOG Advisory Committee
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Nicole Varela, MD – Work Group Member
Anesthesiology, Winona Health
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2014 Mar

Measure Maintenance

Scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature.

Date of Next Anticipated Revision

The next scheduled revision will occur within 24 months.

Measure Status

This is the current release of the measure.

This measure updates a previous version: Danielson D, Bjork K, Card R, Foreman J, Harper C, Roemer R, Stultz J, Sypura W, Thompson S, Webb B. Preoperative evaluation. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jul. 61 p.

The measure developer reaffirmed the currency of this measure in January 2016.

Source(s)

Card R, Sawyer M, Degnan B, Harder K, Kemper J, Marshall M, Matteson M, Roemer R, Schuller-Bebus G, Swanson C, Stultz J, Sypura W, Terrell C, Varela N. Perioperative protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2014 Mar. 124 p. [124 references]

Measure Availability

Source available for purchase from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy. Also available to ICSI members for free at the ICSI Web site External Web Site Policy and to Minnesota health care organizations free by request at the ICSI Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; Phone: 952-814-7060; Fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; E-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on July 20, 2010.

This NQMC summary was retrofitted into the new template on July 22, 2011.

This NQMC summary was updated by ECRI Institute on August 31, 2011, June 12, 2013 and again on November 3, 2014.

The information was reaffirmed by the measure developer on January 13, 2016.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.

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Related Content

NGC GUIDELINE SUMMARIES

  • NGC:010503
  • 1997 Sep (revised 2014 Mar)

Perioperative protocol. Health care protocol.


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