Surgical Quality Improvement Plans
GUIDANCE DOCUMENT
An Ontario Surgical Quality Improvement Network Programmatic Initiative
1
Contents
Background .....................................................................................................................................................3
What is the Ontario Surgical Quality Improvement Network (ON-SQIN) and the National Surgical Quality
Improvement Program (NSQIP)? ................................................................................................................3
Surgical Quality Improvement Plans ...........................................................................................................3
Purpose of this document ...........................................................................................................................4
Resources ...................................................................................................................................................4
Who should be involved in SQIP development? .............................................................................................5
SQIP Development Process ...........................................................................................................................6
A Step-by-Step Overview to SQIP Development ........................................................................................6
Figure 1: Example of a SQIP Workplan ..................................................................................................7
SQIP Workplan ...............................................................................................................................................8
AIM ..............................................................................................................................................................8
MEASURE...................................................................................................................................................9
CHANGE ...................................................................................................................................................10
Surgical Quality Improvement Plan Submission Process .............................................................................11
Figure 2: Timeline for SQIP and Progress Report Submission ...........................................................11
Surgical Quality Improvement in Action ........................................................................................................12
Reporting on SQIP Progress.........................................................................................................................12
Figure 3: Progress Report Template .....................................................................................................13
General Guidance for Completing your SQIP Progress Report ...................................................................14
Conclusion.....................................................................................................................................................14
Appendix A: SQIP Frequently Asked Questions & Answers ....................................................................15
Appendix B: How to Create, Implement & Sustain a Surgical Quality Improvement Plan .......................17
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Background
What is the Ontario Surgical Quality Improvement Network (ON-SQIN) and the National
Surgical Quality Improvement Program (NSQIP)?
The Ontario Surgical Quality Improvement Network (ON-SQIN) is a community of surgical teams across
Ontario who share a commitment to surgical quality improvement and the achievement of long-term
surgical quality improvement goals.
Led by a surgeon champion and supported by the CEO, hospital teams participating in the network:

Access an online collaborative space where surgical teams can discuss best practices, share
innovations, and discover ways of improving surgical care in Ontario

Benchmark surgical outcomes and contribute to the comparison of outcomes from across Ontario

Empower providers to implement quality improvement initiatives

Establish common improvement goals
A key aspect of participating in the Network is the implementation of the American College of Surgeon’s
National Surgical Quality Improvement Program (ACS-NSQIP). NSQIP-ON, Ontario’s version of this
internationally recognized program, is designed to measure and improve the quality of surgical care and is
applicable in academic, community and rural hospital settings.
Health Quality Ontario supports the spread of NSQIP across the province in order to help hospitals collect
high quality clinical data, which when combined with a quality improvement program designed to decrease
surgical complications, improve patient care and outcomes, and decrease the cost of health care delivery.
NSQIP uses a prospective, peer-controlled, validated database to quantify 30-day, risk-adjusted surgical
outcomes, enabling the comparison of outcomes among all hospitals in the program. This information
helps organizations measure and understand their outcomes, and compare their outcomes to benchmarks
and to those of other participating sites. Collaboration between participants accelerates improvement
through shared learning.
Surgical Quality Improvement Plans
A Surgical Quality Improvement Plan is a programmatic initiative for members of the Ontario Surgical
Quality Improvement Network. The high-quality clinical data extracted from NSQIP can be used to
determine where there may be opportunities for improvement. Based on this data, surgical teams can
develop a programmatic Surgical Quality Improvement Plans (SQIPs) to identify and implementspecific
quality improvement initiatives. Creating a SQIP will allow ON-SQIN members to track baseline data,
change ideas, process measures and outcomes.
By developing a SQIP and submitting it to the Surgical Quality Improvement Network, common barriers to
improvement can be identified and teams that have identified similar quality improvement goals can be
connected through the Network.
To support SQIP development and ongoing quality improvement, a SQIP report will be shared with ONSQIN participants following the submission of this year’s programmatic Surgical Quality Improvement
Plans. The report will highlight surgical quality improvement initiatives currently underway in Ontario,
progress made toward quality improvement targets, and overall trends. Capturing the improvements that
have been achieved will be important to support further program roll out in Ontario.
This work plays a role in the provincial common quality agenda and contributes to Ontario’s vision for a
high-performing health care system. Moving forward with your Surgical Quality Improvement plan your
organization is welcome to share this work with your hospital CEO to support and reflect any broader
organizational plans.
3
Purpose of this document
This Surgical Quality Improvement Plan Guidance Document has been created to support ON-SQIN teams
in the development of a Surgical Quality Improvement Plan. It provides a brief overview of the elements
that should be incorporated into your SQIP.
Resources
The HQO website hosts the Ontario Surgical Quality Improvement Network’s online platform, a forum
which surgical teams can discuss best practices, share local innovations, and discover ways of improving
surgical care in Ontario. Visit the Ontario Surgical Quality Improvement Network regularly to find updates
on tools and resources and information on, but not limited to, Surgical Best Practices, surgical bundles, the
Institute for Healthcare Improvement (IHI) Open School, Improving and Driving Excellence Across Sectors
(IDEAS), and Enhanced Recovery After Surgery (ERAS). If anyone in your Surgical Quality Improvement
Team requires access to our Surgical Quality Improvement Network, please email nsqip@hqontario.ca
4
Who should be involved in SQIP development?
The development and implementation of initiatives outlined within a Surgical Quality Improvement Plan
depend on the involvement and engagement of a site’s senior leaders, clinicians, staff, and patients.
Below are the potential roles of the individuals and groups involved in SQIP development.

The Surgical Quality Improvement Team
The Surgical Quality Improvement Team should include the Surgeon Champion, the Surgical
Clinical Reviewer as well as staff surgeons, as well as other clinicians, nurses and staff. This team
should update the Chief of Surgery and the Hospital Quality Committee on SQIP development and
its progress throughout the year.

Chief Executive Officer or Executive Director
The Chief Executive Officer (CEO) or Executive Director (ED) is accountable for the hospital’s
formally submitted QIP and, along with the Chief of Surgery, oversees the Surgical Quality
Improvement Team as they develop the Surgical Quality Improvement Plan.

Surgeon Champion
The clinical leadership of an organization is critical to improvement efforts. Senior leaders,
including the Surgeon Champion, should spearhead the development of the annual SQIP and
should aim to involve all clinicians and staff in SQIP development and implementation. The
Surgeon Champion should also certify (through the accountability sign-off at the bottom of the
SQIP template) their approval of the SQIP.

Surgical Clinical Reviewer (SCR)
The role of the Surgical Clinical Reviewer is data compilation and data entry into the NSQIP
database. Therefore, the SCR informs SQIP development and works closely with the Surgical
Quality Improvement Team to identify opportunities for surgical quality improvement.

Clinicians, Service Providers and Staff
Other clinicians, service providers and staff who are part of the surgical team also have an
important role to play in SQIP development. Quality improvement best practice demonstrates the
importance of engaging various staff in quality improvement efforts. These staff members act as a
link between the Surgical Quality Improvement Team and the rest of the organization and are a
key source of information for clinicians and service providers.

Patients, Family Members and Caregivers
Patients, family members, and caregivers can offer valuable insight into processes by sharing their
experiences of care. Teams should look for opportunities to include the patient’s voice through
patient engagement and co-design.
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SQIP Development Process
Surgical Quality Improvement Plans are to be developed by the hospital’s Surgical Quality Improvement
Team, based on data extracted from NSQIP. The Chief of Surgery, senior managers, clinicians, other
staff, should be involved in the creation and implementation of the SQIP, while, the Surgeon Champion
and senior managers should monitor progress toward the targets identified in the SQIP.
A Step-by-Step Overview to SQIP Development
1. Use NSQIP data to identify your current performance and/or baseline for one to three indicators that
your team wishes to improve upon. HQO provides resources to support indicator selection in your
SQIP. Indictors can be found by visiting the Ontario Surgical Quality Improvement Network on-line
platform, tools and resources section, and are also provided in your Surgical Quality Improvement
Plan Workplan document.
2. Create a plan to address the areas for improvement identified in Step 1. Developing a plan includes:
 Setting and providing a rationale for a target
 Identifying change ideas to be tested
 Identifying methods and process measures
3. Enter your indicators, baseline data, targets, target rationale, change ideas, methods, process
measures and goals for the process measures, along with any comments, into the SQIP Workplan
template, leaving the ‘Year End Performance’ column blank (See Figure 1).
4. After six months, complete the Progress Report, which will help you determine if you have improved
on any of your team’s indicators (See Figure 3).
5. To demonstrate shared accountability, we ask that prior to submission, the SQIP is signed by the
Surgeon Champion, the Chief of Surgery, and the Hospital CEO.
6. After 12 months, teams will be required to review their SQIPs to determine if their targets were met.
During this phase, teams will fill in the ‘Year End Performance’ column that was left blank in Step 3.
Add any comments about your results in the right-most column.
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Figure 1: Example of a SQIP Workplan
Leave this column blank when submitting your SQIP Workplan in Sept 2015.
In March 2016, you will enter your performance to determine whether your
team has improved on each of their identified indicators.
In this column, comment on why you chose each
indicator. A final column (not shown) is also provided
for comments on end-of-year performance.
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SQIP Workplan
The Ontario Surgical Quality Improvement Network and NSQIP-ON is designed to provide hospitals with
a surgical quality improvement program that has been proven to improve patient care and outcomes, and
decrease surgical complications and the cost of health care delivery. The aim of both initiatives is to
improve outcomes and patient experiences.
The SQIP Workplan was designed to resemble your organizational hospital QIP. Moving forward with
your Surgical Quality Improvement plan your organization is welcome to share this work with your hospital
CEO to support and reflect any broader organizational plans.
The SQIP Workplan is the main component of the Surgical Quality Improvement Plan, as it details your
organization’s improvement targets and initiatives. The SQIP Workplan contains three sections, which
align with the Model for Improvement.1 These sections are:



AIM: What are we trying to accomplish?
MEASURE: How do we know that a change is an improvement?
CHANGE: What changes can we make that will result in the improvements we seek?
Health Quality Ontario has a suite of resources to support SQIP development. This suite of resources
includes the Quality Compass, a searchable tool designed to support Quality Improvement teams as they
work to improve health care performance in Ontario. Visit the Getting Started tab of the Quality Compass
to learn about how to create an aim, measure or generate change ideas.
AIM
The AIM section of the Workplan is divided into two sections:
1) Quality Dimension: In order to advance quality improvement and facilitate health system
transformation, all dimensions of quality should be leveraged within the Surgical Quality
Improvement Plan. To complete this section, please select the quality dimensions that your AIM
is focused on:





Safety
Effectiveness
Access
Patient-Centered
Integrated
2) Objective: Your objective or defined aim statement is used to clearly establish your quality
improvement objective and answer the question “What are you trying to accomplish?”
1
Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing
Organizational Performance (2nd Edition). San Francisco, California, USA: Jossey-Bass Publishers; 2009, p.32.
8
MEASURE
This section seeks to answer the question: “How do we know that change is an improvement?”
Measurement is an essential part of implementing and testing ideas for improvement. Measures tell your
team whether their changes are actually leading to quality improvement. Once you have identified your
objective, you can match your measures to the improvements you want to see.
The specific elements of this portion of the Workplan are addressed below:
Measure/
Indicator
Current
Performance
(Baseline)
Surgical Quality Improvement Teams choose objectives for improvement based on
NSQIP data. To support this identification process, teams should consider ACS and
provincial benchmarks (where available) and best practices for each objective. Your
team can review your organization hospital’s QIP to identify any alignment.
What is the organization’s current performance or rate associated with the
indicator? Use NSQIP to find your current performance (baseline) data.
Target (for this
fiscal year)
This column should indicate the targeted outcome the organization expects to
achieve by the end of the fiscal year. Some key considerations when setting targets
are:
• Teams should consider a target that represents what they hope to achieve
within six and 12 months (see Figure 2 for timelines)
• Teams should set stretch targets in high priority areas
• Teams should not set targets below baseline. If an organization cannot meet
the baseline, information should be included in the ‘comment’ section to
elaborate on why they cannot.
Target
Justification
Organizations should justify their performance improvement targets. Organizations
may wish to consider the following common justifications for stretch targets:
• Provincial benchmark (where this exists)
• Theoretical best
• Matching best performance in other jurisdictions
• Reduce defects/waste/wait time
• 90th percentile among peers
• Match the rate of improvement attained by other leading organizations
• Match provincial average (appropriate only for organizations whose
performance is far below average)
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CHANGE
This section seeks to answer the question: “What changes can we make that will result in the
improvements we seek?” In this section you will outline what your QI team plans to do that will contribute
to you reaching your objective and your outlined measures.
Planned
improvement
initiatives
(Change Ideas)
This column allows teams to detail the quality improvement initiatives being put in
place that will lead to the desired improvement. Change ideas should be identified
for all objectives. Best practice indicates that initiatives that consider several change
ideas for each objective show the most improvement. A new row should be added
for each new change idea. The Workplan consists of an “indicator and Change
Ideas tab” that will provide you with some suggested change ideas.
Methods
This column allows teams to explain the process the organization will follow in order
to achieve its quality improvement goals. Include details on how change ideas will
be selected, assessed, and analyzed.
Process
Measures
Process measures help teams determine whether or not their change ideas are
leading to improvement. Processes must be measureable as rates, percentages,
and/or numbers over specific timeframes. For example, “the number of staff who
watch hand-hygiene video per month”; “the number of catheter insertions per
month”; “the number of patients undergoing procedures longer than four hours who
receive antibiotic re-dosing in the Operating Room“.
Goal for
change ideas
This is the organization’s numeric goal, specifically related to the process
measures, and is used to track progress on change ideas within specific
timeframes. E.g. “95 % adherence by Aug 31, 2016”. Setting aggressive or ‘stretch’
targets for these process measures and implementing the change ideas to achieve
them will help organizations accelerate their improvement on priority indicators.
Comments
This is the place for any additional comments about change ideas or quality
improvement initiatives. Comments may provide context or cite organizational
factors for success.
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Surgical Quality Improvement Plan Submission Process
Surgical Quality Improvement Plans are to be submitted in three phases:
Phase 1: Due September 30, 2015:
Completed SQIP Workplans are to be submitted by September 30, 2015, using the Workplan template
included in this package. Please leave the Year-End Performance column blank for now – this section will
be updated in March 2016.
Once the Workplan is complete, and signed by the Surgeon Champion, Chief of Surgeon and Hospital
CEO (bottom of Workplan Template), submit the approved Workplan to NSQIP@hqontario.ca.
Phase 2: Due March 31, 2016
Between September 30, 2015 and March 31, 2016, teams should continue to gather monthly data and
report on their progress at the six-month mark, using the Progress Report template (the second tab in the
Surgical Quality Improvement Plan Workplan template).
Once the Progress Report is complete, have the Surgeon Champion, the Chief of Surgery and the
Hospital CEO sign their approval in the space provided at the bottom of the template and submit the
approved Progress Report to NSQIP@hqontario.ca.
See “Surgical Quality Improvement in Action” for more information on progress reporting.
Phase 3: Due September 30, 2016
By September 30, 2016, teams should fill out the ‘Year End Performance’ column of the SQIP Workplan
to demonstrate the gains that have be made over the course of the year. At this stage, teams can add
any comments regarding performance to the final column in the Workplan.
Once the Workplan is complete, have the Surgeon Champion and Hospital CEO sign their approval in the
space provided at the bottom of the template and submit the approved Workplan to
NSQIP@hqontario.ca.
Figure 2: Timeline for SQIP and Progress Report Submission
September
Draft SQIP Workplan
Submitted To HQO
October
30-Sep-15
September
Final Report
(Workplan with Year End results)
submitted to HQO
March
Submit 6-Month Progress
Report to HQO
November December
January
February
March
April
May
June
July
August
September
30-Sep-16
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Surgical Quality Improvement in Action
Once Phase 1 of the SQIP has been completed, it is important to ensure that your team continues to work
towards the goals identified in the plan. Continuous surgical quality improvement can be facilitated by:
1.
Enlisting the Surgeon Champion to act as the reporting lead, whose role it is to track performance
on the SQIP. The Surgeon Champion will work with colleagues and with the team to drive change
in your organization.
2.
Building capacity within the organization to track performance on change ideas on an ongoing
basis.
3.
Meeting regularly with your Surgical Quality Improvement Team to track your quality improvement
planning and to discuss and monitor progress made on the achievement of the goals identified
within the SQIP.
4.
Participate in ON-SQIN teleconferences, learning opportunities, and forums on the ON-SQIN
website.
Reporting on SQIP Progress
In addition to identifying areas for improvement, organizations should ensure a system is in place that
allows for continuous monitoring and tracking of performance on the commitments and priorities set out in
their SQIPs.
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Figure 3: Progress Report Template
Surgical Quality Improvement Plans (SQIP): Progress Report for 2015/16
This template has been provided to assist with reporting on the progress of your organization’s SQIP.
Please review the text in the second row of the template, which outlines the requirements for each reporting
parameter. The Progress Report template can be found in the third tab in the Surgical Quality Improvement
Plan Workplan template.
Guidance for completing the Progress Report
Priority
Indicator
State the
name and
definition of
the indicator
listed in the
2015/16
SQIP.
Baseline
as stated in
Workplan
Target as
stated SQIP
Workplan
State the
performance
associated with the
indicator that was
included in the
2015/16 SQIP.
State the
performance goal
that was included in
the 2015/16 SQIP.
The stated
performance goal
indicates the
outcomes that the
team expected it
would be able to
achieve by the end
of the current year
(e.g., 2015/16).
Progress to date
For each of the
indicators listed, state
the team’s current
level of performance
associated with the
priority indicator.
Comments
Describe how the SQIP
was implemented for
each indicator. Please
consider the following
when completing this
section: - What did you
learn about the root
causes of the current
performance?
- Were the proposed
change ideas
implemented? Why or
why not?
- If implemented, have
the changes helped you
to achieve or surpass
the target?
- What will you do to
further improve on this
indicator?
Surgeon Champion (please print):
Surgeon Champion (signature):
Chief of Surgery (please print):
Chief of Surgery (signature):
Hospital CEO (please print):
Hospital CEO (signature):
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General Guidance for Completing your SQIP Progress Report
The SQIP Progress Report is an opportunity for your team to reflect on your SQIP Workplan and report
on any progress made on your indicators. It is intended to demonstrate your team’s commitment to
upholding the principles of accountability, transparency, and ensuring the delivery of high quality patient
care.
Helpful tips:
 Reflect on SQIP targets: Report on the progress made on all indicators in your SQIP. Include the
indicator(s) identified in the previous SQIP, the performance target stated, and progress to date.
 Provide context through the comment section. Use this section to explain how the performance goals
stated in the SQIP could be improved, describe the challenges related to meeting the targets
outlined in the SQIPs, and elaborate on the team’s commitment to meeting the performance targets
outlined in their SQIP. When completing this section, consider the following issues:
o What did you learn about the root causes of the current performance? Were the proposed change
ideas implemented? Why or why not?
o If implemented, have the changes helped you to achieve or surpass the target determined by
your organization?
o What will your team do to further improve on this indicator? What were your key lessons learned?
Please refer to the FAQ (Appendix A) for more information on the Progress Report. A simplified “How to
create, implement and Sustain Surgical Quality Improvement Plans” can be found in Appendix B.
Conclusion
Surgical Quality Improvement Plans are a significant opportunity for Surgical Quality Improvement Teams
to improve the quality of care they provide to patients and to contribute improved health system
performance.
This document was designed to help teams use NSQIP data to inform their quality improvement efforts
and report on their progress. Surgical Quality Improvement Teams across the province are encouraged to
use their SQIPs to drive change within their organizations and to keep patients at the centre of the circle
of care.
This is a journey; excellence has no limit.
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Appendix A: SQIP Frequently Asked Questions & Answers
Q1.
What is a Hospital Quality Improvement Plan (QIP) is an organization-owned plan that establishes
a platform for quality improvement that can be used to harmonize efforts to improve quality of care
across the health care system. While most health care sectors are familiar with developing QIPs as
a way to express quality goals and targets for their organizations, the sectors are at a different starting
points when it comes to developing QIPs. The expectation is for health care organizations to have
their QIPs in place, publicly posted, and submitted to HQO by April 1 every year.
Ontario has now had close to four years of experience with Quality Improvement Plans (QIPs),
which started in the hospital sector and, over the course of the last few years, extended to interprofessional primary care organizations, Community Care Access Centres (CCACs), and LongTerm Care (LTC) Homes.
Q2. What is a Surgical Quality Improvement Plan and how does it relate to the Hospital QIP and the
broader health care system?
Surgical Quality Improvement Plan (SQIP) is a programmatic initiative as part of the Ontario
Surgical Quality Improvement Network. It is a way to track the high-quality clinical data extracted
from NSQIP and use it to drive and monitor improvement. Your SQIP will help you to track
baseline data, determine change ideas, and monitor process measures and outcomes
Health care organizations may be undertaking a range of quality improvement projects at any
given time. Communicating with your hospital’s QIP team about your SQIP goals will assist in the
organization and prioritization of quality improvement projects, and ensure they are aligned with
the overall quality improvement goals of the hospital and system at large.
By developing a SQIP and submitting it to the Surgical Quality Improvement Network, common
barriers to improvement can be identified and teams that have identified similar quality
improvement goals can be connected through the Network.
To support SQIP development and ongoing quality improvement, a SQIP report will be shared
with ON-SQIN participants following the submission of this year’s programmatic Surgical Quality
Improvement Plans. The report will highlight surgical quality improvement initiatives currently
underway in Ontario, progress made toward quality improvement targets, and overall trends.
Capturing the improvements that have been achieved will be important to support further program
roll out in Ontario.
This work plays a role in the provincial common quality agenda and contributes to Ontario’s vision
for a high-performing health care system. Moving forward with your Surgical Quality
Improvement plan your organization is welcome to share this work with your hospital CEO to
support and reflect any broader organizational plans
Q3. What is the objective of SQIPs?
A. The objective of the Surgical Quality Improvement Plan (SQIP) is to facilitate an action-oriented
approach to surgical quality improvement and to help surgical teams measure whether their quality
improvement efforts are making an impact on patient outcomes. The SQIP is where teams can
record the clinical data extracted from NSQIP, determine baseline data and targets, document
change ideas, as well as process measures and the outcomes of their quality improvement efforts.
Q4. Who needs to develop a SQIP?
A. All organizations involved in the Ontario Surgical Quality Improvement Network (ON-SQIN) and
enrolled in the National Surgical Quality Improvement Program (NSQIP) are expected to develop
and submit a programmatic Surgical Quality Improvement Plan.
Q5. How do I submit my SQIP to HQO?
A. Surgical QI teams are to submit their SQIP Workplan by September 30, 2016. The completed
Progress Report is to be submitted by March 31, 2016, and the final Workplan (including year-end
results) is to be submitted by September 30, 2016. All submissions are to be submitted to
NSQIP@hqontario.ca.
15
Q6. Does the Ministry of Health & Long-Term Care also need to receive a copy of my SQIP?
A. No, Surgical QI teams do not need to submit their plans to the ministry.
Q7. What priority areas should my organization focus on in our SQIP?
A. The high-quality clinical data extracted from NSQIP can be used to determine where there may be
opportunities for improvement. Teams can review their current performance (baseline) against
NSQIP benchmarks, while the ON-SQIN provides additional resources to support indicator selection
for your SQIP.
Q8. Who is responsible for developing a SQIP in my organization?
A. The development and implementation of initiatives outlined within a Surgical Quality Improvement
Plan depends on the involvement and engagement of a site’s senior leaders, clinicians, staff, and
patients. For more information on the roles related to SQIP development, please see the Who should
be involved in SQIP development? section on page 4 of guidance document.
Q9. What does HQO do with the SQIPs once they are submitted?
A. By developing a SQIP and submitting it to the Surgical Quality Improvement Network, common
barriers to improvement can be identified and teams that have identified similar quality improvement
goals can be connected through the Network.
To support SQIP development and ongoing quality improvement, a SQIP report will be shared with
ON-SQIN participants following the submission of this year’s Surgical Quality Improvement Plans.
The report will highlight surgical quality improvement initiatives currently underway in Ontario,
progress made toward quality improvement targets, and overall trends.
Q10. Can I make changes to my SQIP after it has been submitted to HQO?
A. Surgical Quality Improvement Teams can update their SQIPs after submission for their own
improvement purposes. Should a team have an error in their SQIP that they wish to correct, they
can contact NSQIP@hqontario.ca.
Q11. Will quality improvement targets be set for my surgical team?
A. Surgical Quality Improvement Teams set their own quality improvement targets within their SQIPs.
Teams can also look to Health Quality Ontario and the ON-SQIN for additional resources and
information. Also, NSQIP has established targets or benchmarks that can be used as a guide.
Q12.What happens if my surgical team doesn’t meet the targets set out in our SQIP?
A. SQIPs are not an accountability or compliance tool, but rather a tool to guide a surgical team’s
quality improvement efforts. However, it is important to remember that a SQIP is a formal
commitment that a team makes to its patients/residents/clients, staff, and community to improve
quality through focused targets and actions. To deliver on this commitment, all teams should be
striving to achieve the targets they set out for themselves.
Q13. Is my organization required to publicly post its SQIP?
A. Surgical teams are not required to publicly post their SQIPs.
However, transparency is an important way of ensuring that our publicly-funded health care system
remains accountable to the people of Ontario, it is also a way for health care organizations to foster
dialogue with the communities they serve. By publicly posting their SQIPs, health care organizations
can communicate local quality improvement priorities to patients, clients, and staff and demonstrate
their overall commitment to quality.
Q14. If I need help with my SQIP, who do I contact?
A. Questions about completing SQIPs should be directed to NSQIP@hqontario.ca.
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Appendix B: How to Create, Implement & Sustain a Surgical Quality Improvement Plan
Getting Started
 Organize ongoing Quality Improvement team meetings to discuss the development and
implementation of the Surgical Quality Improvement Plan (SQIP)

Tip: Engage senior leaders, clinicians, and surgical staff. Consider ways to incorporate
the voice of your patients

Review your surgical team’s data or collect baseline (current performance) data on
potential indicators. A list of possible quality indicators is available in the Surgical Quality
Improvement Plan Workplan

Consider which indicators your organization will focus on in the SQIP. Surgical Quality
Improvement Teams are encouraged to select areas where performance is not at
benchmark and/or are priorities for both the organization and patients
Defining the Problem
 Highlight areas where your current state does not meet your target. Enter your current
performance (baseline) into the SQIP Workplan

In addition to current performance data, use information from your strategic plan,
accreditation results, critical incidents and complaints, and capture the voice of your
customers using staff/patient satisfaction surveys

Initiate a Communication Plan (CP Template) to share progress with the stakeholders.
Understanding your System
 Brainstorm improvement opportunities and change ideas to be tested. Engage your
community stakeholders (i.e., other parts of the health care system and the public) for
priority setting

Tip: Consider engaging patients, families, clinical, administrative and support staff

Enter the change ideas, methods and process measures for each indicator on your SQIP
Workplan
Designing and Testing Solutions
 Obtain approval/‘sign-off’ from the hospital CEO, the Chief of Surgery and the Surgical
Champion on a final draft of the SQIP Workplan no later than September 30th, 2015

Submit the SQIP to NSQIP@hqontario.ca by September 30th, 2015.
Begin testing change ideas using the Plan-Do-Study-Act (PDSA) method (PDSA
Template)

Share results of your measurements and tests of change. Share “stories” of challenges
and successes. Celebrate!

Use a Sustainability Planner to help make changes stick
Implementing and Sustaining Solutions
 Formalize and standardize changes into policies/procedures, orientation documents, job
descriptions, and education programs. Document new processes

Create an ongoing plan to review measurements to identify how you are progressing

Discuss lessons learned with staff and patient/family councils. Share improvement stories
and evaluate their impact and any feedback from patients. Regularly consult with health
system partners about cross-sector opportunities for improvement

Tip: Document what works, and how you have overcome challenges. Learn even more
by sharing with others through the ON-SQIN
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
Engage the team in creating a Spread Plan. (SP Template)
Spreading Change
 Design a system for monitoring performance and the achievement of any
commitments/priorities established in the SQIP

Implement your team’s Spread Plan

Communicate broadly. Export the Progress Report and Workplan for your files. Publish
your results and share through speaking and poster presentations

As you implement change ideas and process measures throughout the year, update the
SQIP Progress Report, comparing it against the previous year’s SQIP priorities and
targets. Indicate which change ideas you have implemented and what lessons you’ve
learned

By March 31st, 2016, at the six month mark, submit the Progress Report component of
the SQIP NSQIP@hqontario.ca.
The Progress Report indicates what was learned about current performance, whether
proposed changes were implemented, results of the change ideas, actual progress
related to targets set, what will be done to improve further, and lessons learned. The
Progress Report is used to inform the development of the SQIP final report in September
2016
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