SCIP tip sheet seeks to involve patients

Initiative begins consumer-focused phase

The Oklahoma City, OK-based Surgical Care Improvement Project (SCIP) has begun a consumer-focused phase that will include the tip sheet, "Steps to Safer Surgery," which gives patients specific questions to ask physicians and nurses before surgery to ensure the care provided will reduce the likelihood of complications.

The goal of the SCIP national partnership is to reduce by 25% the incidence of the most common preventable surgical complications — infection, blood clots, and adverse cardiac and respiratory events — by 2010. SCIP's steering committee includes the following organizations:

  • Agency for Healthcare Research and Quality (AHRQ);
  • American College of Surgeons;
  • American Hospital Association;
  • American Society of Anesthesiologists;
  • Association of periOperative Registered Nurses;
  • Centers for Disease Control and Prevention;
  • Centers for Medicare & Medicaid Services (CMS);
  • Institute for Healthcare Improvement;
  • Joint Commission on Accreditation of Healthcare Organizations;
  • Veterans Health Administration.

Questions on the two-page tip sheet range from "If I take medicine for heart disease, should I keep taking it?" to "If I need antibiotics before surgery, when will I receive the antibiotic and for how long?"

"This really is the piece we've been waiting so long to put in place," says David Hunt, MD, Medical Officer in the Office of Clinical Standards and Quality at CMS. "We've been work on SCIP for more than three years, and one of the things we wanted was a comprehensive program of getting physicians, hospitals, and patients on board."

While patients are an integral part of the plan, "We first made sure we had a pretty good campaign to educate and notify physicians, surgeons, nurses — all the perioperatives," Hunt explains. "Then, there was a concerted campaign to make sure hospital executives were on board – which started a year ago."

The whole point of the previous two phases, he says, was to lay the foundation for the patient phase. "But we wanted to make sure that when the information went out to the patients they would not get blank stares from staff when they asked their questions," he explains. "We want to make sure patients are empowered to understand they can get information and actually participate in things that will help the quality of their surgical experience."

This deliberate plan to make sure the perioperative team and hospital executives were on board was worked through the QIOs. "We wanted to make sure we had an education plan," Hunt explains. "We had things we saw as great opportunities for improvement. Then, we designed measures around those opportunities."

But measuring alone is not enough, he continues. "We had to make sure we had a system of interventions hospitals could use and be taught, either through QIOs or downloaded using tools on the Internet," he says. "We got many people on board in terms of looking at what to improve, how to measure, and what staff can do to change things."

One of the most important things to know about SCIP, Hunt continues, is that it is all about systems. "It has to do with the integration of very complex systems of care delivery," he notes. "Any one component in a given hospital may work incredibly well, but you need that integration and synergy of the perioperative team. All things need to be integrated for them to reliably happen – for example, how to make sure the patient gets antibiotics on time at the optimal time, which is within an hour of incision. This requires a very intricate choreography involving the surgeon, the pharmacy, the perioperative holding nurse, the surgical nurse, and so forth."

Previous QI programs in this area, he asserts, would target one thing, like "surgeon writes the order." "That still does not mean the patient gets the antibiotic on time," he emphasizes.

Patients are critical

Kerm Henriksen, PhD, Human Factors Advisor for Patient Safety at AHRQ, agrees with Hunt that patients are critically important to the SCIP project.

"Certainly for the last 10 to 15 years there has been greater awareness of the role patients can play in improving the care they receive in hospital settings," he notes. "One of the reasons for that is there is such variation in some of the practices when it comes to safer care in the hospital. We know what the right thing to do is, but not every place does the right thing right."

Therefore, he continues, patients need to be aware of what those right things are, as well as which hospitals practice them. "The tip sheet is arming patients with the knowledge of what is right," he explains. "SCIP has identified four target areas: reducing surgical-site infections, preventing adverse cardiac events, preventing venous thromboembolism, preventing respiratory complications. If I was a patient going into the hospital, I would want to talk to someone in the surgical unit and find out what this hospital does to prevent surgical-site infections or adverse cardiac events and how they control for blood clots. These are good questions to ask, because when it comes to surgery, doing things the wrong way can have adverse consequences."

"We've all recognized that medicine was too paternalistic," adds Hunt. "This is a sort of recognition that the patients are number one, and they should be active participants in their care. We know we can reliably do things if we make sure the patients are engaged, and serve as an opportunity to check things like wrong-site surgery, pre-op meds, and so forth. They are just another very involved set of eyes, ears, and brains that we desperately need for reliable delivery of care."

But is there evidence the providers will react positively to the proposed queries? "That's a good question," says Henrisken. "Some might take offense, but in general I think the surgical care team likes to see their patients are well informed about some of the risk factors in surgery. It shows, among other things, that they are taking an interest in their profession."

[Editor's note: The consumer tip sheet, "Steps to Safer Surgery" is available at:]

[For more information, contact: David Hunt, MD, Medical Officer, Office of Clinical Standards and Quality, Centers for Medicare and Medicaid Services, 7500 Security Boulevard Baltimore, MD 21244. Phone (800) 633-4227.

Kerm Henriksen, PhD, Human Factors Advisor for Patient Safety, Agency for Healthcare Research and Quality, 540 Gaither Road, Suite 2000, Rockville, MD 20850. Phone: (301) 427-1364.]