Author(s): Deborah Cardenas, DNP, MSN, RN, CPHQ
Director Quality Improvement Service Lines
WellSpan Health

Deborah Cardenas, DNP, MSN, RN, CPHQ, serves as Director of Quality Improvement for Surgery, Neuroscience and Orthopedic Service Lines at WellSpan Health. Dr. Cardenas is an accomplished healthcare professional with over 40 years of experience in nursing where she brings a wealth of nursing knowledge in critical care, medical-surgical and ambulatory care. Throughout her career, she has served in Quality, Risk Management and Patient Safety roles, affirming her dedication to reliable patient care. Dr. Cardenas obtained her Master of Science in Nursing and Doctor of Nursing Practice degrees. She has hospital nursing education experience, along with undergraduate and graduate education experience. Her commitment to advancing the nursing profession is reflected in her role as President of the Pennsylvania State Nurses Association, where she has served since June 2021.Dr. Cardenas is dedicated to identifying new and innovative ways to continuously improve patient outcomes and elevate the standard of care.

Competency Domain: Quality Leadership & Integration

Description: In a large healthcare system, there are advantages to leveraging standardized sedation committees, a standardized sedation audit tool and convening all facility sedation committees to report to a system committee. To ensure consistent practices across the system, the System Safe Procedural Sedation Committee provides an opportunity to identify sedation safety trends, address sedation concerns which may impact all facilities, work toward solutions, opportunities for improvement, system policy updates and standardization across all entities. Safe procedural sedation administration by non-Anesthesia providers must be structured, evaluated and follow regulatory standards. An open dialogue between non-Anesthesia and Anesthesia physicians enhances collaboration and relationships. Problem: Standardize sedation committees and sedation audit tool across a large health system. Additionally, convene all sedation committees from each facility into a system sedation committee to identify sedation trends, concerns, opportunities for improvement and system policy review and revisions. Measurement: Audit tool for data collection based on system sedation policy and regulatory requirements. Standardized committee charter at both the facility and system level. Analysis: The audit tool was drafted based on the system sedation policy and shared with system representatives. Audit tool changes were made based on feedback. Results and opportunities for improvement are shared at the facility level sedation meetings and may be brought to the system meeting. Implementation: Standardized sedation committee charter, system sedation committee charter and audit tool for all facilities where conscious sedation is used. Obstacles included resistance to use of standardized audit tool format. Discussed audit tool feedback with facilities. Tool changes made as needed. Key stakeholders present, provide rationale for changes. Results/Discussion Opportunities to identify and address sedation trends and concerns across the system, work toward solutions, and collaborate on system sedation policy review has been beneficial. Providing an open dialogue between non-Anesthesia and Anesthesia providers enhances engagement and teamwork across the system.

Evaluation: Complete Poster Evaluation