Jefferson Surgical Solutions


Through the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®), the Department of Surgery continually searches for ways to further improve the quality of surgical care delivered to our patients. As our NSQIP Surgical Clinical Nurse Reviewer, Randi Altmark plays a pivotal role in collecting and maintaining the data necessary to identify and act on opportunities for improvement.

When she returned to Jefferson to assume this role in 2006, Altmark brought more than 20 years of experience in nursing – including seven years as a Jefferson OR nurse and experience as an OR manager and business manager for surgical services as well as labor and delivery.

Altmark maintains Jefferson’s ACS NSQIP database by abstracting relevant clinical data from patient charts. With data points spanning pre-op, intra-op and post-op variables, the database enables Jefferson to generate risk-adjusted reports and trend the quality of surgical care. As a participant in this program, Jefferson can benchmark itself against other hospitals in order to evaluate its own performance and cultivate best practices. In addition to maintaining the database, Altmark works closely with Surgeon Champions Herbert E. Cohn, MD, Scott Cowan, MD, and Stacey Milan, MD and other health care providers to develop and execute process improvements.

The NSQIP program enables surgeons, anesthesiologists, nurses and other clinicians to view summaries of patient outcomes based on objective clinical data. Working with others, they can modify their practice to provide improved care to surgical patients. For example, NSQIP data has been used to help drive improvements in rates of surgical site infections.

“It’s rewarding to know that my relatively small but vital contribution can greatly benefit patients receiving surgical care,” Altmark says. “And, I enjoy collaborating with surgeons and clinicians, who all contribute their expertise and unify around a common goal of providing the best-quality care possible for Jefferson patients.”

“Above all, I’m very grateful to work in a collaborative environment with people who recognize that while we’re doing a great job, we can always do better,” she concludes.