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Beating NSQIP’s Lock date. April 2012. Cases by Cycle. INTRODUCTION. Presentation:. Our Struggle and Triumphs with ACS NSQIP -Kelli Jennison-Gustafson RN SCR. Our Struggles and Triumphs with ACS-NSQIP. Nanaimo Regional General Hospital Kelli Jennison-Gustafson RN SCR. NRGH.

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Beating NSQIP’s Lock date

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Beating NSQIP’s Lock date

April 2012

Cases by Cycle



Our Struggle and Triumphs with ACS NSQIP

-Kelli Jennison-Gustafson RN SCR

Our Struggles and Triumphs with ACS-NSQIP

Nanaimo Regional General Hospital

Kelli Jennison-Gustafson RN SCR


  • Acute Care Facility and Trauma Center

    234 acute care beds

    22 long tem care beds.

  • Population: over 300,000 residents

  • Busiest ER in Vancouver Island

  • We employ over 1,700 individuals locally


  • Classic Multispecialty

  • 2 FT SCRs

In the beginning…

  • July 2011

    1st day on the job - Boston conference

  • August 2011

    Office set-up

    2 weeks of full time online training and learning

  • Sept 2011


Unfamiliar territory

  • CPT and ICD Codes

  • Data cleaning

Recipe For Disaster

  • 1 cycle = 1 month

  • OR log procedure ≠ OR report procedure

    - days to pick cases

  • Paper-based and electronic charts

  • Waiting Game: Data entry to workstation until all information is complete

  • Continue with the above process knowing that the system won’t work!

Angela to the rescue

  • First site visit on December 5.

  • Tips and tricks :

    - at a “glance” when selecting cases

    - use oversampling for excluded cases

  • CPT coding techniques

  • Data cleaning template

Rescue continues!

  • Open the EMR/paper chart, start the case in the workstation.

  • No more paper reviews: saves time and reduces data input errors

  • “Tips and tricks” for post op occurrences:

    - check labs, diagnostics, surgeons notes and discharge summaries

  • Vacation cycles-spaced, watch lock out dates

More changes

  • New OR form- “Report of Operations”

    -accurate OR procedure by surgeon

  • Cheat sheet of CPT and ICD-9 codes commonly used at our hospital

  • New “pre-op admission form” being created; NSQIP friendly history questions

How are we doing now?

  • Up to date with our cycles

  • 89% 30 day follow up on all cases

  • Data cleaning – watch lock out dates

  • Looking at our “raw data”

  • Created a custom field, preoperative antibiotics vs. incision time

Then and Now

Our Current Cycle Tree

What if we fall behind again?

  • Raw reports will not be “real time”

  • Difficult to tell if new QI initiatives are working or need tweaking

  • No time for follow up and data cleaning

  • Missed cases

  • Stressed SCR’s again

You can do it too!

Thank you

Advantages of being at least 60 days behind lock date:

*Holidays/sick time – you can use vacation cycles anytime!

*Report back to teams- real-time reports

*Time to find missing data

*Verify/Confirm data with SC and anesthesia

*Clean and discuss interesting cases

*Act on unusual trends timely

Taking advantage of your vacation cycles:

Using vacation cycles need a little bit of planning

When do you plan to use it?

- SCR holidays

- catch up with lock date

- Short/Difficult cycles

Taking advantage of your vacation cycles:

SCR Holidays:

You can use vacation cycles anytime if you are working on cases that are at least 60 days to lock date

- Can somebody take over your cases?

- What is your status? how far behind are you?

- Can you use your vacation cycle without compromising your 30-day follow-up ?

- Is there a potential that you will abandon charts while you are away?

Taking advantage of your vacation cycles:

SCR Holidays:

When you come back, you want to make sure that you have enough time to work on your cases that are close to lock date

- review, ff-up and clean

Taking advantage of your vacation cycles:

Catch up with lock date:

- What is your status? how far behind are you?

- What format do you use to report back to teams? Run charts, SPC charts, bar charts

Interval? Monthly, Quarterly

- What is the impact of using vacation cycle in your data?

Taking advantage of your vacation cycles:

Short/Difficult Cycles

– not enough cases (cycle 46, easter weekend)

46 cycles – 4 vacation cycles = 40 cycles

42 cycles x 40 cases = 1680 cases/year

If: 40 cycles x 40 = 1600

and: 2 cycles x 15 = 30 (cycle 46 and easter)

so: 1600 + 30 = 1630 (short 50 cases)

– Cycle includes difficult cases

Goal: Find areas for improvement

We want these cases!!!

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