1. © Copyright, The Joint Commission Joint Commission Center for Transforming Healthcare (CTH) Partnering for Success in Reducing Surgical Site Infections Cynosure Health Summit 21 st May 2012

2. © Copyright, The Joint Commission Siew Lee Grand-Clément RN, MSN, CPHQ Center Project Leader: Surgical Site Infections Collaborative Joint Commission Center for Transforming Healthcare (CTH) 2

3. © Copyright, The Joint Commission Objectives 1.To explain the collaborative working model of the Joint Commission Center for Transforming Healthcare. 2.To describe the problem solving methodology used in reducing Surgical Site Infections. 3.To identify the key stakeholders involved and describe the process of forming an effective multi- disciplinary team. 4.To demonstrate the use of infection control and prevention practices in driving improvements. 5.To illustrate the roles of nursing in process improvement initiative. 3

4. © Copyright, The Joint Commission 4

5. Introduction to CTH-Vision All people always experience the safest, highest quality, best-value health care across all settings. One Vision 5

6. © Copyright, The Joint Commission Why the CTH was Created  Our Mission - Transform health care into a high reliability industry and to ensure patients receive the safest, highest quality care they expect and deserve.  Presents a new approach to address critical safety and quality problems sought by The Joint Commission, health care organizations, patients and their families, physicians and other clinicians, and other public and private stakeholders 6

7. © Copyright, The Joint Commission What’s Different About the Center?  Unique approach to improvement:  Center for Transforming Healthcare (CTH) collaborating with HCOs and hospital leaders where lean, six sigma are already working  Powerful process improvement tools (RPI) –Underlying causes, targeted solutions –Integrated change management for acceptance and accountability  Engaging industry coupled with reach of TJC –Leadership Advisory Council Members & Sponsors –Ability to spread solutions to 19,000+ accredited health care organizations in US 7

8. © Copyright, The Joint Commission Introduction to CTH-Targeting Root Causes 8

9. © Copyright, The Joint Commission Introduction to CTH-Projects  Project 1 – Hand Hygiene Compliance  Project 2 – Wrong Site Surgery  Project 3 – Hand Off Communication  Project 4 – Surgical Site Infections –With American College of Surgeons  Project 5 – Preventing Avoidable Heart Failure Hospitalizations –With American College of Physicians  Project 6 – Safety Culture  Project 7 – Preventing Falls with Injury  Project 8 – Reducing Sepsis Mortality  Project 9 – Medication Safety 9

10. © Copyright, The Joint Commission PROJECT #4: SURGICAL SITE INFECTIONS Collaborate with American College of Surgeons & NSQIP measurement system leveraged. Seven participating hospitals: 1.Mayo Clinic, MN 2.Cleveland Clinic, OH 3.Stanford Hospital & Clinics, CA 4.OSF Saint Francis, IL 5.Northwestern Memorial Hospital, IL 6.North Shore LIJ, NY 7.Cedars-Sinai Medical Center, CA 10

11. © Copyright, The Joint Commission Systematic Approach to Problem Solving – Surgical Site Infections (1) 11 The Center worked with the American College of Surgeons to determine the scope of the SSI project, since there is a wide range of surgeries and procedures that can develop SSIs – each with its own unique set of complications and challenges. To help narrow the scope of the project, the following criteria were used to identify a specific procedure that:  Is common across different types of hospitals  Has significant complications with an adverse clinical impact  Hospitals have significant opportunities to improve performance  Has high variability in performance across hospitals

12. © Copyright, The Joint Commission Systematic Approach to Problem Solving – Surgical Site Infections (2) 12 Scope: All patients undergoing colorectal surgery (emergency and elective) regardless of who (i.e., which clinical discipline) performs the surgery. NSQIP CPT codes for colorectal surgery. All types of Surgical Site Infections (Superficial Incisional, Deep Incisional, and Organ/Space). Exclude: Trauma and Transplant patients. Patients under 18 years of age. Process starts: Pre-admission Process ends: 30 days post surgery Metrics to improve: Defects: Colorectal Surgical Site Infections (SSIs) Goal: Reduce colorectal surgical site infections by 50%. Primary: Observed Rate of Patients with Colorectal SSIs (within 30 days of the procedure) Secondary: Observed over Expected (O/E) Ratio for Colorectal SSIs

13. Dominique LaRochelle, MHA Project Manager Cleveland Clinic Quality & Patient Safety Institute 13

14. © Copyright, The Joint Commission Quality and Patient Safety Institute  25 August 2015  14 Cleveland Clinic 14

15. Quality and Patient Safety Institute  25 August 2015  15 Developing Effective Teams… Who is going to solve this important problem? 15

16. Patient Quality and Patient Safety Institute  25 August 2015  16 Complex Environment Physicians Unit SecretariesCoders Case ManagersPatient Access Operations Administration Nurses How to Align? 16

17. Quality and Patient Safety Institute  25 August 2015  17 Identifying a Project Team - RACI RACI Quality Improvement  Quality Management  Colorectal Services  Perioperative Services  Inpatient Colorectal Services  Pharmacy  Infection Control / Infectious Disease  Environmental Services  Safety / Clinical Risk / Accreditation  Sterile Processing  Data  17

18. Quality and Patient Safety Institute  25 August 2015  18 Project Team  Who is going to solve this important problem? SponsorChief Quality Officer ChampionSurgeon Leader Process OwnerColorectal Surgery Black BeltDirector of Quality Improvement Core TeamQuality Improvement Project Manager Quality Management Peri-operative Services Nurse Managers (Admission & PACU) Nurse Manager Colorectal Services OR Nurse Manager Colorectal Services Wound Care specialist Infection Prevention 18

19. Quality and Patient Safety Institute  25 August 2015  19 Project Team  Subject Matter Experts: StakeholderRepresented Area Quality and Patient Safety Institute  Quality Improvement  Quality Management  Safety  Accreditation  Clinical Risk Management  Infection Control / Infectious Disease  Data Resource Management Colorectal Services  Digestive Disease Institute – Administration & Physician Leadership  Quality Review Officers  Pre-op: Nursing, Education, Staff, Management, Anesthesia, Dietary  Post-op: Nursing, Education, Staff, Management, Wound Care, Dietary Surgical Operations  Administration / Physician Leadership  PACE, PACU, IMPACT clinics  Nursing, Staff, Anesthesia Pharmacy  Pharmacists Environmental Services  OR & Inpatient management Sterile Processing  Surgical Tech Management / Education  Equipment Vendors Data  NSQIP  ARKS  Nursing Informatics  Medical Records Data / Health Data Services  Business Intelligence (EBI) 19

20. Quality and Patient Safety Institute  25 August 2015  20 Analysis Strategy Cause/Effect Analysis Multi-Vari Analysis Benchmarking & SMEs Impact/Effort Analysis Improvements Validation 20

21. Quality and Patient Safety Institute  25 August 2015  21 SIPOC Analysis  Met with 3 teams of core team members to map peri- operative process: Pre-, Intra-, Post- Op  Expanded upon SIPOC to explore cause & effect relationships  Fishbone Diagram  Cause & Effect scale: Numerical score, 1-5, based on process variable and its relationship to our output; SSI –Subjective findings using area experts –Narrowed the scope to help us focus on a few key processes –Key processes can then be further explored using objective data 21

22. SIPOC 22

23. Quality and Patient Safety Institute  25 August 2015  23 Cause & Effect Analysis 23

24. Cause & Effect Analysis  Met with SIPOC teams (area experts) to review recorded processes and narrow our focus using a rating scale 1-5 (Subjective findings) 24

25. Quality and Patient Safety Institute  25 August 2015  25 Cause & Effect Analysis  Priority processes were identified to help focus the team’s interventions Processes Identified as Having the Greatest Impact on Risk of SSI Pre- Op  Diagnosis / Disease  Focus on chronic inflammation  Isolation Patient, Pre-op infectious agent  Glucose Levels  Diet / Nutrition  Antiseptic Shower or Bath  Patient Demographics  BMI specifically Intra- Op  Surgeon Scrub Technique (HH)  Aseptic Practice / Sterile technique  Equipment Sterilization Technique  Air Filter Maintenance Post- Op  RN Hours per Patient Day  Wound Care Technique and Materials (Including HH)  OR  PACU/ICU, Patient Hand-off Communication  Post-op Glucose Levels  Patient Diet / Nutrition  Post- Op Medications  Wound Care Specialist, CWOCN 25

26. Quality and Patient Safety Institute  25 August 2015  26 Analysis Strategy Cause/Effect Analysis Multi-Vari Analysis Benchmarking & SMEs Impact/Effort Analysis Improvements Validation 26

27. Quality and Patient Safety Institute  25 August 2015  27 Validating Progress: OR Audits  Detail observations (April – May 2011)  Multidisciplinary team  Broad scope, low n  Circulating nurse checklist (May – October 2011)  Led by circulating nurse  Narrow scope – bundle focus  High n – intent to capture all eligible cases 27

28. Quality and Patient Safety Institute  25 August 2015  28 Challenges Encountered  Impacting how surgeons practice  Data are imperfect –  Sampling  Incomplete process data are available  Resources are limited  Data needed to support improvements  Improvements need to be made 28

29. Sasha Madison, MPH, CIC. Manager Infection Prevention and Control Department 29

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31. Confidential- Protected by California Evidence Code Section 1157 Infection Prevention & Control  Role in this Project: − Subject Matter Expert (SME) − Core team member − Prior to this project the role of the Infection Preventionist was focused on surveillance.  Defining cases, abstracting data, calculating rates  Interventions to decrease SSIs were often individual – not system based 31

32. Confidential- Protected by California Evidence Code Section 1157 Infection Prevention & Control  Role in this Project: (during project) − Core team member: “ team participant”  Involved in project in all phases: from Define to Control − Subject Matter Expert (SME)  Defining different data sources with team and reviewing them, along with the definitions, with the team  NSQIP vs NHSN − Interventions to decrease SSIs were system based 32

33. SHC SSI Project Phases & Elements Milestone Key Elements DefineIncidence of Surgical Site Infections in colorectal surgery is high, variable, and represents opportunity for improvement. MeasureReduce colorectal surgical site infections by 50% (Observed and Observed/Expected) Analyze (Based on statistical analysis of SHC data) ImproveFocus on identified causes, target solutions, patient outcomes ControlCorrelate interventions with SSI outcomes and create sustainability plans for any intervention that successfully decreased SSIs Statistically Significant Variables (Potential Risk Factors for SSI) Potential Identified Variables /Opportunities  Wound Disruption (0.003)  OR Duration (0.066)  ASA Class > 2 (0.015)  Open/Laparoscopic Procedure (0.054)  Total Hospital LOS (0.036)  Lowest Patient Intra-Operative Temperature  Post-Operative Wound Care  Hand Hygiene  Dressing Removal at 48hrs  Post-Operative Bathing  Surgical Closure  Glove Change Prior to Closing Fascia  Separate Colorectal Closure Tray  Tissue Irrigation - Irrigation Solution Type  Note: Actual Interventions in blue & Monitoring in green Note: Above variables found to be statistically significant, however not entirely modifiable. - No Interventions Made 33 DMAIC

34. Confidential- Protected by California Evidence Code Section 1157 34 NHSN Publicly Reported Cases- MIDAS Focus Study MIDAS Focus Objectives: Detailed abstraction of elements with identified areas of opportunity Data will be analyzed for any potential trends and to serve as a guide for further interventions Surgeon specific SSI rates Surgical Quality Council Dashboard will include SSI outcomes

35. Confidential- Protected by California Evidence Code Section 1157 Next Steps & Opportunities  MIDAS Focus Study on Publicly Reported Cases − Infection Control SSI surveillance in July/Aug 2011 identified an opportunity in colorectal surgery − Data collection focused on elements which are not captured elsewhere − Need for individual physician communication of infections identified  Antibiotic Stewardship − Instituted February 2012 − Review of current prophylaxis guidelines and empiric therapy  Based on best practice learning through collaborative, continue glove changes & separate/clean closing instruments 35

36. Elisa Nguyen, RN, MS, CMSRN. Patient Care Manager 36

37. Confidential- Protected by California Evidence Code Section 1157  Role of Nursing Wound Management Postoperative Phase 37

38. Confidential- Protected by California Evidence Code Section 1157  Key stakeholder − In all processes that involves caring for patients  Nursing involvement from different levels collaborating with the Core Team − staff nurses − Unit Educators − managers  Process improvement − We own majority of the process − What are gaps in the process that could be improved  Education and training − Lead the education and training the frontline nurses 38 Role of Nursing

39. Confidential- Protected by California Evidence Code Section 1157  Existing Policy and Procedure (P&P) − No existing one for post-op wound care management − Utilized another service’s P&P as a model to create one for colorectal  Shared governance approval − Drafted P&P went to one of the physician lead for review − Hospital nursing council for final review and approval 39 MD/RN Collaboration

40. Confidential- Protected by California Evidence Code Section 1157 40 Post-Operative Wound Management & Surgical Brochure DMAIC Utilizing Surgical Brochure to Reinforce critical need of Post Operative Wound Management Protocol

41. Confidential- Protected by California Evidence Code Section 1157  Unit level staff identified process of implementation − Unit Clerk – added the audit tool to admission packet, color coded the patient’s name of locator board − Primary Nurse – completed the audit − Resource Nurse – double checked that audit was completed  Data collector − Quality manager in charge of data processing 41 Tracking the Process Nursing Action Focus: Conducted to better understand hand hygiene at each phase of post-op care and to assure that we keep the incisional wound and drain insertion sites free from contamination in the early post-operative period 41

42. © Copyright, The Joint Commission What is next? How can you participate in this effort? 42

43. © Copyright, The Joint Commission CTH Operating Model Project Selection Create Solutions, Pilot Test, Build Spread Determine Topic Solve with Participating Organizations Pilot Test Integrate Solutions w/ TST Launch TST    18 to 24 months    43

44. © Copyright, The Joint Commission Introduction to CTH-Spread  Improvement spread through Targeted Solutions Tool ™ –Web-based tool free to Joint Commission accredited organizations –No knowledge of RPI methodology needed –Data analysis conducted by the tool, not the user –Tool walks user through process of: –Measuring current state –Determining root causes –Selecting targeted solutions –Control of process after implementation 44

45. © Copyright, The Joint Commission Benefits of becoming a pilot site  Assisting the Center in its aim to transform health care into a high- reliability industry by solving health care’s most critical safety and quality problems  Access to the Center solutions prior to national release  Access to the tools developed and used by the participating hospitals in the Surgical Site Infections Project 45

46. © Copyright, The Joint Commission Pilot participant expectations Create team Measure performance Real- Time Analysis Implement targeted solutions Validate improve ments Webex conference calls occur approximately every 2 weeks throughout pilot 46

47. © Copyright, The Joint Commission Feel Free to Contact Us  Any information related to the Joint Commission Center for Transforming Healthcare, the SSI Collaborative Project and Pilot Participation, –Please contact Siew Lee Grand-Clément at SGrand-Clement@jointcommission.org SGrand-Clement@jointcommission.org –Website: www.centerfortransforminghealthcare.org www.centerfortransforminghealthcare.org 47

48. © Copyright, The Joint Commission QUESTIONS OR COMMENTS? 48