Surgical Program surpasses National Surgical Quality Improvement Program (NSQIP) standards

surgery program

The National Surgical Quality Improvement Program (NSQIP) is a data-driven, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care.

North York General regularly monitors and reviews infection rates and uses this information to execute best practice protective measures to continually improve patient care and safety. For the last two years it has been part of the hospital's Quality Improvement Plan (QIP) to monitor and prevent surgical site infections in Colorectal Cancer surgeries.

This measure is reported on a quarterly basis.
Hospital Odds Ratio = 

Hospital Odds Ratio

An inter-professional quality improvement (QI) initiative was undertaken to implement the evidenced based practices to decrease Surgical Site Infections. A project charter was developed with this goal and objective:

Goal: To reduce surgical site infection rates amongst the general surgery patient population

Objective: Reduce the SSI odds ratio from 1.78 (Jul 2016-Jun 2017) to 1.00 by June 2019.

Nine bundle components were implemented in 2017

  • Mechanical bowel prep and oral antibiotics
  • Preoperative (chlorhexidine) showers
  • Perioperative glucose control
  • Perioperative normothermia
  • Wound Protectors
  • Antibiotic Standardization
  • Hair Removal
  • Skin Antisepsis
  • Closing Trays and gloving

The surgical program has met and surpassed their goal for the National Surgical Quality Improvement Program from Health-Quality Ontario quality initiative.

The team started in 2017 with a ratio of 1.78 which is above the benchmark of 1.0. After implementing nine bundle components, the team is now at 0.76 – an incredible achievement.

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