The Joint Commission and Cleveland Clinic Reducing Colorectal Surgical Site Infections

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1 The Joint Commission and Cleveland Clinic Reducing Colorectal Surgical Site Infections Cleveland Clinic Experience for NSQIP Conference Guido Bergomi 26 July, 2014

2 Mission Dr. Frank E. Bunts Dr. George W. Crile Care for the sick Investigate their problems Educate those who serve Dr. William E. Lower Dr. John Phillips

3 Culture: Values Quality Innovation Teamwork Service Compassion Integrity Quality and Patient Safety Institute 20 August

4 Quality Focus Safety: PSIs, HACs, HAIs, Pressure Ulcers, Falls, Safety Events Quality: Core Measures, Readmissions, Mortality Patient Experience: H-CAHPS Quality and Patient Safety Institute 20 August

5 Quality Focus Safety: Keep me safe. Quality: Heal me. Patient Experience: Be nice to me. Quality and Patient Safety Institute 20 August

6 Key Enterprise Goals 2013 Heart Failure Readmissions Post Op Complications (aggregate PSIs) Quality and Patient Safety Institute 20 August

7 At Project Start Good, Bad, and Ugly SSI tied to our enterprise goals(though not top tier). The goal mattered to our mission. NSQIP data was present. NSQIP data not fully socialized. Existing perspective on severity and validity. Limited evidence-based direction available. Lots of competing priorities. NSQIP data present, but not fully utilized e.g. timing. Quality and Patient Safety Institute 20 August

8 Improvement Bundle Pre-operative antibacterial bath/shower with hibiclens soap Standard, sterile skin prep by OR scrub nurse Glove change and sterile sleeve application after intra-op DRE Glove and instrument change for skin closure Saline irrigation of SQ before skin closure Standard application of wound dressing Continuation of OR wound dressing for 48 hours New dressing trial: Mepilex Clean, standard dressing change (if necessary) Quality and Patient Safety Institute 20 August

9 OR Checklist Results Average Bundle Compliance: 88.46% % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Pre-op Skin Cleansing Standard Skin Prep DRE Glove/Sleeve Change Instrum ent / Glove Change at Skin Closure Wound Irrigation Dressing Change Quality and Patient Safety Institute 20 August

10 Bundle 1 Challenges Improvements not immediately apparent. Changes based on Quality Improvement principles of standardization not supported by evidence. Team support largely from Nursing surgeon support was secondary, and changes were perceived to cost time/money. Quality and Patient Safety Institute 20 August

11 Bundle 2 Elements: Oral ABX with mechanical bowel preps Wound protector use Evidence based Surgeon led and supported but leadership buy-in was not achieved Process measures not present Quality and Patient Safety Institute 20 August

12 NSQIP CORS Incisional SSI 0.25 Incisional SSI includes superficial + deep (not organ) Bundle 1 Bundle Quality and Patient Safety Institute 20 August

13 Key Enterprise Goals 2013 Heart Failure Readmissions Post Op Complications (aggregate PSIs) 2014 Hospital-wide Readmissions VTEs PSI-12 SSIs Colorectal, Abdominal Hysterectomies Quality and Patient Safety Institute 20 August

14 Current Reality Leadership support Physician engagement Clear accountability to standardized data Quality and Patient Safety Institute 20 August

15 Progress Used prior bundling work Gained consensus around process changes and measurement techniques with leadership support (physician, nursing) Implemented with focus on communication, education, accountability Quickly achieved bundle compliance > 80% Implemented short cycle directional data review Case review where failures occur Quality and Patient Safety Institute 20 August

16 NSQIP CORS Incisional SSI 0.25 Incisional SSI includes superficial + deep (not organ) Bundle 1 Bundle 2 Bundle Quality and Patient Safety Institute 20 August

17 Opportunities and Lessons Learned Short Cycle data critical to supporting Quality Improvement efforts and decisions. Front-line physician support is essential. Value exists in standardizing practice but implementing those improvements can be challenging. Quality and Patient Safety Institute 20 August