1) Decreasing post-operative renal failure; currently analyzing data for potential improvement opportunities. 2) Decrease prolonged post-operative ventilation; reviewing protocols to determine optimal changes to current care sets. The scope of thiswork includes review of pharmaceuticals and care team approach to early extubation. 3) Increase compliance with indicators of the Surgical Care Improvement Project; this includes selection and timing of prophylactic antibiotics, timely discontinuation. Care sets have been updated to reflect current standards and these have been implemented.

MGHP has a multi-disciplinary improvement initiative focused on increasing the number of patients who have a door-to-balloon time of 90 minutes or less. Analysis of individual cases and potential patterns and trends has been done & is ongoing. Several processes have been changed and overall variation has been decreased. Work continues on this indicator.

Baseline data was collected on the use of beta blockers for all major elective surgeries. The multi-disciplinary team developed a protocol for beta blocker use and we are finalizing that protocol for implementation. Ongoing monitoring of compliancewith this protocol will follow implementation. We continue work on tight blood glucose control for surgical and medical patients.

Baseline data was collected on the use of beta blockers for all major elective surgeries. The multi-disciplinary team developed a protocol for beta blocker use and we are finalizing that protocol for implementation. Ongoing monitoring of compliancewith this protocol will follow implementation. We continue work on tight blood glucose control for surgical and medical patients.