Surgical Services Council Meeting

Surgical Services Council Meeting

Minutes

May 2, 2017

0900

Attendance

Present: A. Brondo, J. Gaynor, E. Harding, A. Lacourciere, T. Sandomenico, S. Silverstein, Erica Zippo (guest)

Time meeting adjourned: 11:00

Magnet Component / Pillar / Topic / Discussion Leader / Discussion / Outcome/To Do
Transformational Leadership / Quality / Nursing Division Strategic Plan / J. Gaynor / Strategic plan was distributed to members. All council work should be aligned with strategic plan and the tenets of Magnet.
All projects will be documented using CSI templates to assist with Magnet story development.
Tammy recommends utilizing a template when working on projects to facilitate story development / Andrea will provide Magnet story templates to council members
Structural Empowerment / People / Membership
Review of Bylaw
Meeting time / J. Gaynor
J. Gaynor / New members introduced.
Need OR representation.
Need ASD representation
Bylaw were reviewed pertaining to length of meetings, member expectations
Meeting day/time discussed. All members agree that current meeting day and time is acceptable. / Andrea will recruit OR member
Janet will reach out to Michelle and ASD to recruit member
Exemplary Professional Practice / Quality
Quality / NSQIP Functional Status
Endoscopy Documentation
PACU Documentation / S. Silverstein
A. Lacourciere
E. Zippo / Sam notes that WPH participates in National Surgical Quality Improvement Program (NSQIP). Nursing documentation must reflect patient’s prior functional status, which is currently missing. Current ASD documentation was reviewed to determine where changes/additions would be appropriate. Suggestions to review Montefiore EPIC documentation for functional status documentation.
Janet questions the necessity to document Basic Mobility Assessment utilizing the BMAT for surgical/endoscopy outpatients.
Changes to Endoscopy intra procedure documentation were reviewed. Changes were previously vetted with Endoscopy staff.
Revised documentation reviewed with Eric Zippo. Changes approved.
PACU Phase I documentation requires documentation of antibiotic given in OR: time of 1st dose and time of last dose. Erica notes that the rule requiring this documentation is currently not functioning. Requesting approval to re-activate the rule, which will ensure that documentation is completed as required.
All present agree that rule should be re-activated. / Andrea will look into EPIC documentation.
Council will determine appropriate changes to documentation to meet
NSQIP requirements
Email sent to M. McKenna re: need for BMAT on outpatients
Andrea will forward changes to Erica for revision.
Erica will reactivate the documentation rule.
New Knowledge, Innovations, and Improvements / Quality / Surgical Directions / A. Lacourciere / SS Division/council members have worked heavily on Surgical Directions. Discussion re: inviting K. Semmelrock, L. Massias, and S. Diaz to report on work thus far. / Janet will reach out to Katherine, Lorisse and Shannon to invite them to share their work

Next meeting: Tuesday, June 6, 2017- 0900

Respectfully submitted, J. Gaynor

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