Educate, Empower, Engage: A Collaborative Interdisciplinary Call to Action for Reducing Surgical Site Infections

Transcription

1 Educate, Empower, Engage: A Collaborative Interdisciplinary Call to Action for Reducing Surgical Site Infections Proceedings and Recommendations from the 2011 Infection Prevention Leadership Summit E. Patchen Dellinger, MD, Richard P. Dutton, MD, MBA, Steven Gordon, MD, Charlotte L. Guglielmi, MA, BSN, RN, CNOR, Lisa Spence Huber, BA, CRCST, ACE, FCS, Kathleen Kohut, RN, MSN, CIC, CNOR

2 Introduction Americans today undergo an average of seven operations during their lifetimes with 50 million procedures done in the U.S. annually. 1 Indeed, surgical site infections (SSIs), as one of the most common surgical complications, continue to be a real problem causing real pain and suffering in real patients. Furthermore, there is a very real financial impact for the patient and the hospital or outpatient surgical center, based on direct medical costs of managing SSIs, as well as reduced turnover of available hospital beds due to increased length of stay. If you combine these costs and reduced revenue potential with negative repercussions of SSIs on overall patient health and satisfaction (including word-of-mouth negative publicity arising from patients sharing a negative experience with friends, family, and colleagues), and the evolving CMS standards that track and reimburse, in part, based on patient satisfaction, the institutional financial impact of SSIs could become even more staggering. HAIs and SSIs: The Scope of the Ongoing Challenge Healthcare acquired infections (HAIs) remain an ongoing threat to patient health and recovery, with little progress having been made since the first Institute of Medicine report, To Err is Human, was published in Efforts seeking ways to eliminate HAIs continue, including a recent call to action from multiple organizations focused on the problem. 3 Surgical site infections (SSIs) represent a problematic subgroup of HAIs. According to the Centers for Disease Control (CDC), approximately 1 in 20 hospitalized patients acquire an HAI, 4 with an estimated annual direct medical cost to hospitals between $28.4 and $45 billion. 5 The cost benefits of prevention range from $5.7 billion (assuming 20 percent of infections are preventable) to as much as $31.5 billion (assuming 70 percent of infections are preventable). 3 Estimates for the number of surgical site infections (SSIs) range from more than 200,000 to as many as 500,000 annually, representing as much as 22% of total HAIs It has been estimated that SSIs may result in as many as 3.7 million additional hospitalization days and an annual overall cost of 1.6 billion in the United States. 11 Untold investments toward the goal of reducing SSIs have been made in research, development of policies and procedures, and implementation processes within and across team disciplines working in or supporting the surgical setting. But, based on the largely unchanged scope of the problem and continuing adverse effects on patients and health care costs, new or stepped-up approaches are called for. The fourth Infection Prevention Leadership Summit (Oct., 2011) provided a fresh look at challenges and barriers associated with reducing SSIs. The summit was a unique interdisciplinary forum that allowed the shared expertise, experience and ideas from more than 80 subject matter experts, noted faculty, professional and patient society leaders and industry partners to be focused on a single goal improving patient care through reducing SSIs. Page 2

3 The overall consensus and necessary call to action from these partners is to educate, empower, and engage (E 3 ) all parties, from c-suite to hospital staff to patients and their families or caregivers, while also leveraging the power of unity among societies, such that all are working and communicating collaboratively to effect and maintain positive change that will consistently reduce the scope of the SSI problem. Educate, Empower, Engage and the Surgical Home Steps taken toward positive change must stay focused on the patient s perspective and experience. Similar in concept to the medical home, the surgical home is a patient-centric model recognizing that every patient requiring surgery enters a continuum of care that begins at diagnosis and concludes with the return to normal activities. (Fig. 1) Notably, there are several points along the continuum where positive steps can be taken to reduce the risk of SSIs. While conceptually simple, effective implementation with demonstrable outcomes requires rigorous application of the interdisciplinary collaborative E 3 approach to the surgical home model. Moreover, there must be new expectations to drive leadership support, from the hospital Board of Directors and c-suite or ambulatory surgical center management to team leaders representing infection prevention, the surgical staff (including surgeons, anesthesiologists and nurses), sterile processing, environmental services, surgeon office staff and other disciplines within the surgical home. The call to action for leadership is to establish and maintain a working environment/culture that optimizes education and training for staff, empowers every individual at every level to do The medical home, or the patient-centered medical home, is defined as "an approach to providing comprehensive primary care... that facilitates partnerships between individual patients, and their personal providers, and when appropriate, the patient s family," toward the goals of better access to health care, increased satisfaction with care, and improved health. (ref: Joint principles of the patient-centered medical home. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, March, 2007.) Based on concept espoused by American Society of Anesthesiology and others suggesting comprehensive coordination and management of surgical patients will reduce complications and improve efficiencies and cost-effectiveness of perioperative care. Page 3

4 the right thing, and expects the highest level of engagement and quality execution for staff members individually and collaboratively across disciplines. Because the surgical home concept is based on a singular continuum of care, it is imperative that cross-functional collaboration and communication be seamless and synergistic. In essence, the surgical home should operate as a High-Reliability Organization, avoiding undesired outcomes with every patient, every surgical procedure, every day. (Fig. 2) The Educate, Empower, and Engage (E 3 ) Discipline Educate: Going beyond the required didactic courses and certifications. In an environment as complex and multi-faceted as a healthcare institution, training must also focus on understanding the interactions and relationships across departments, demonstrating personal competency, reporting data and outcomes, and utilizing electronic medical records. Empower: Adopting a culture that delineates responsibility and increases accountability. In an institution at the top of its game, every discipline and every person within the surgical home feels empowered to carry out their duties, work effectively across teams, and make important contributions. In the healthiest organizations, empowerment also can represent opportunities to appropriately speak up without fear of retribution when something is wrong, missed, or when a process can be improved. Engage: Making a psychological investment in patient care with all disciplines performing their jobs with a level of pride beyond simply achieving formal indicators of success. This translates to optimum execution getting it right with every patient, every time. Page 4

5 Infection Prevention Leadership Summit Based on growing recognition and a sense of urgency that additional ideas and practices are needed to effectively reduce SSIs, a fourth Infection Prevention Leadership Summit was convened in October The summit, titled All for None: Eliminating HAIs through Knowledge, Collaboration and Leadership, was a unique forum that brought together professionals representing infection prevention/epidemiology (IP), operating room staff (OR), central sterile supply department (CSSD) and other functions associated with prevention of SSIs. Additionally, formal sponsorship, representation and participation in the summit also was provided from the Association of PeriOperative Registered Nurses (AORN), Association for Professionals in Infection Control and Epidemiology (APIC), Society for Healthcare Epidemiology in America (SHEA), International Association of Healthcare Central Service Material Management (IAHCSMM), National Patient Safety Foundation (NPSF), and Surgical Infection Society (SIS). The summit agenda, which comprised presentations from the primary authors of this paper, followed by breakout sessions to further evaluate approaches for reducing SSIs, was developed by these professional and patient organizations in collaboration with 3M and its partners, Sage Products, Belimed, and Rochester Medical which provided a supporting educational grant, as well as meeting space and logistics for the event. Summit breakout sessions included faculty, society representatives and attendees. Areas of need addressed by the breakout groups were derived from a qualitative survey conducted pre-summit asking participants to identify challenges faced within their institutions impeding SSI reduction. Four core themes emerged based on survey results: Compliance with policies and procedures Teamwork and communications between departments Process improvements Stakeholder participation in process improvements Each group was assigned a theme and charged with identifying approaches for reducing SSIs within the scope of their assigned theme (e.g., Identify Strategies and Actions Needed to Implement Process Improvements for the Reduction of SSIs). Methodologies for facilitating breakout sessions were guided by Six Sigma principles. Special attention was paid to consistent understanding of details and nuances of each theme, including a focus on potential barriers, and potential implementation approaches were identified for overcoming these barriers. Page 5

6 Breakout Sessions: Key Results While each of the four challenge themes represented differing areas of focus, suggested approaches for overcoming barriers for reducing SSIs from the breakout groups were remarkably similar and incorporated the E 3 discipline. Consistently, the improvement-focused strategic imperatives and action steps fell into the following categories: Leadership Communication/Collaboration Data Collection and Sharing Leadership. Everything begins with strong leadership. Leadership based on title (board, chief executives, facilities managers, department heads) is easily recognized and those leaders are expected to provide resources and information, while also modeling and reinforcing behaviors needed to optimize the patient surgical home through the E 3 discipline. Strong leadership must not tolerate attitudes of exceptionalism when it comes to compliance with policies and procedures... everyone must be held responsible and accountable to equal degrees. Leadership at all levels must expect and support personal and inter-disciplinary education and training. This requires a commitment to allocate funding and time for personnel to accomplish this, even in economic times that make cutting these resources very tempting. In addition to the broadly recognized leadership roles of institutional boards of directors and chief executives, leadership at the management function level (departmental heads, team leaders of individual disciplines) is crucial to the day-in and day-out success of their teams. These leaders actively participate in process improvements and take steps to have a clear understanding of roles and responsibilities of team members working together to reduce SSI rates and drive positive change. Like senior leaders, these leaders must also model behaviors that disallow exceptionalism. A recent and ongoing example of strong leadership has been demonstrated by executives of three separate institutions within the same city. They came together to establish and adopt consistent policies and procedures for a variety of issues affecting staff with shared privileges across the institutions. Early examples of these policies included attire guidelines and adoption of time-out protocols prior to surgery. As a result, physicians now act under a harmonized set of rules decreasing the likelihood of policy exceptions and breakdowns in communications. Leaders at the departmental and team levels also are working to make sure there is consistent implementation of the harmonized rules across functions. This provides a model to emulate for leaders of multiple facilities sharing staff, or for leaders of separate facilities sharing staff to help ensure consistency of process development and implementation. Extending this harmonization practice to specific Page 6

7 applications for bundles of policies and procedures focused on SSI reduction is a logical step for helping ensure consistent execution across institutions with shared staff privileges. At the departmental/discipline level, recognizing that it requires both direct patient care providers and support staff to ensure optimal patient outcomes, the importance of having competent and knowledgeable leadership is reinforced in areas such as Central Sterile Supply Department (CSSD). For example, effective CSSD leaders, by understanding all applicable guidelines from the FDA and The Joint Commission and best practice standards issued by the Association for the Advancement of Medical Instrumentation (AAMI) and AORN, create a culture of expectation for staff to provide surgical instrumentation and other medical devices that are properly cleaned, decontaminated, and sterilized, thereby eliminating these devices as possible sources of SSIs. Communication/Collaboration. A fundamental tenet of successful teamwork is effective communication and collaboration. Whether operating within a team or across teams, mutual understanding of individual roles and responsibilities, learning how best to work together, knowing what information needs to be shared by whom and when, and recognizing the importance of regular interactions (both formal and informal) drive effective communication. Considering the number of people and disciplines who contribute to a patient s surgical home experience, effective and sustainable communication and collaboration must occur, and all must be educated, empowered, and engaged. Suggestions from the breakout groups for effective communication and collaboration across teams included creating and utilizing mandated simulation experiences so departments working together can see examples of positive, as well as negative, outcomes and fully understand individual roles (conceptually similar to military training exercises), job shadowing (especially for new staff), and departmental open houses. A very specific example was presented from a hospital that not only holds briefing and debriefing meetings before/after each operation to complete checklists and ensure mutual understanding of the case specifics, but also has monthly meetings of a Surgical Infection Prevention (SIP) Committee. This committee is multi-disciplinary (representatives from each surgical specialty, anesthesiology, OR nursing, infection control, central sterile processing department, pharmacy, and radiology) and reviews SSIs, making determinations about whether specific cases might have been preventable and updating policies based on the committee s findings. Page 7

8 Another example of the power of communication and collaboration that extends to the patient was generated by one of the breakout groups. Their premise was that the patient is often overlooked as an important contributor to the team working to reduce SSIs. Specific recommended corrective actions were: Providing comprehensive education for the patient and family or caregiver on how to reduce risk of SSIs (through brochures, websites, videos and a variety of other techniques): Bestowing a sense of empowerment to the patient to ask questions, seek clarifications, and be fully informed; and, Letting patients know they will be expected to take the instructed steps and confirm back to the staff that the steps were completed. Patient pre-op showering programs are an example. Patients should know that taking showers with an antimicrobial soap prior to their surgical procedure can reduce the bioburden on their skin and reduce the risk of an SSI. Educating the patient by providing instructions, rationale and perhaps even products for use, empowers the patient and further engages the staff in an important SSI prevention strategy. Data collection and sharing. While it seems obvious that one cannot expect alignment with, or track progress toward, a common goal without an appropriate scorecard or dashboard, the issue of generating, collecting, and sharing information was consistently identified by breakout groups as an imperative for improvement. Specific information collected, reviewed and analyzed varies from discipline to discipline (for example, senior leadership will be more interested in cost impact of SSIs whereas surgical and support staffs will be more interested in total numbers/rates of SSI occurrence), but successes cannot be celebrated and failures cannot be corrected without data. Leadership at all levels should create expectations that data-driven metrics will drive steps taken toward the goal of complete patient satisfaction within the surgical home. In turn, there should be a transparent approach to sharing data with staff, those who have the greatest opportunity to change outcomes at the point of care. One example of using data to motivate best practices involved the posting of a simple, easy to read graphic scorecard for a Central Sterilization department. Consistently showing that efforts to improve processes were paying off provided a sense of pride and motivation for the staff to continue efforts toward their sterilization goals. Another example was sharing SSI data with the direct caregivers, the surgical staff in the OR. When the data are good, it validates the hard work they do to protect their patients from harm. When there is room for improvement, the people that can most directly effect positive change can refocus their efforts toward optimizing their patients outcomes. Page 8

9 To quote from the often-cited Alice in Wonderland exchange between Alice and the Cheshire Cat Alice: Would you tell me, please, which way I ought to go from here? The Cat: That depends a good deal on where you want to get to. Alice: I don't much care where. The Cat: Then it doesn't much matter which way you go. Knowing where we need to go and having checkpoints along the way are critical to reducing rates of SSIs. What isn t measured can t be improved. Discussion Without question, the above strategic imperatives and tactical examples, driven by the E 3 approach and customized according to specific needs from institution to institution, represent opportunities to address challenges for reducing SSIs. However, effective leadership is at the root of all of the suggested approaches, through provision of financial and human resources, by creating a culture of collegiality, open communication and collaboration, and adopting an attitude of getting it right every time with every patient. The organizers of the Infection Leadership Summit recognized this and invited Angie Morgan, co-founder of Lead Star, to provide a lecture and conduct workshops with attendees on effective leadership. Takeaways relevant to the challenge of reducing SSIs included the following: Effective leaders make sure their teams have the necessary skills and training, feel empowered to make a difference, and execute at the highest possible level. They drive performance based on meeting and exceeding standards by clearly, consistently and constantly making intentions and expectations clear. Successful leadership qualities include being accountable, having effective communication skills, being decisive and making good, informed decisions. All leaders, whether acknowledged by title or by commitment to a goal or cause, have the ability to positively influence outcomes and inspire others. Powerful, effective leadership is required at all levels and across the entire continuum of care within the surgical home if we are going to take the next steps required to reduce SSIs and improve overall patient satisfaction. Each of us in our individual roles should be expected to provide leadership that is inspirational and effects positive change. For those of us in the trenches, part of our effectiveness is managing up providing data, information, and anecdotes that engage top leadership and allow them to in turn provide what we need to ensure positive patient outcomes and satisfaction. Page 9

10 Conclusions and a Call to Action To continue to wage an effective war against the occurrence of SSIs resulting in a positive impact on patient health and satisfaction with associated reductions in healthcare costs, surgical home teams involved in preparation of the patient, OR, sterilization of instrumentation, and performance of the surgery must not only continue to follow guidelines, policies and procedures within their disciplines, but must also take steps to increase cross-functional communication and collaboration. Moreover, the adoption of the E 3 approach, namely that all levels of staff and leadership are educated, empowered, and engaged, represents a new dynamic environment for creating positive change. Those who attended the Infection Prevention Leadership Summit and contributed to the findings of this paper were charged with implementing steps based on summit results in their institutions immediately upon returning. (Fig. 3) Page 10

11 Furthermore, we believe this represents a call to action for all institutions. Moving forward, we recommend teams supporting the surgical home ask themselves the following questions: Are we having regular meetings with our cross-functional team mates? Do we utilize checklists or other tools to assure mutual intra- and inter-disciplinary understanding of roles and responsibilities for each patient? Do we treat the checklists as just an exercise, or do we make them a serious culture commitment? Are we sharing needs, concerns, opportunities, and successes that could result in further reducing SSIs? What specific steps can we take to achieve getting it right with every patient, every time? Can we improve our metrics and reporting, reviewing key data to guide our progress? For institutional and team leaders, the following questions should challenge your thinking and actions as they pertain to the E 3 educate, empower, and engage discipline and the surgical home: Does our institution invest adequately in our employees to foster a culture of education, empowerment and engagement? Are our board members, chief executives and site managers modeling leadership behaviors necessary to effect reductions in SSIs? What more can we do to ensure adequate resources are available to support reduction in SSIs and improve patient satisfaction? Do all members of the surgical home team have timely access to data that provide a scorecard for their contributions to the SSI reduction goal? Finally, the importance of collaborative efforts among professional and patient societies invested in this issue cannot be overstated. Collaborative opportunities could include: Developing bundles of policies and procedures that go beyond required courses and certifications, creating an interdisciplinary SSI-focused governance structure with leaders representing the OR, Infection Control, Central Sterile Supply and patients/caregivers. Generating organizational best practices mandates for OR staff, Surgical Chiefs, Infection Preventionists and CSSD staff to meet regularly, beyond just immediate pre- or postsurgical procedures. Universally adopting processes that educate, empower, and engage patients as part of the team. Promoting the SSI challenge by organizations to their members and creation of a set of common principles highlighting collaboration to share as part of national meetings, through newsletters, websites, journal commentaries or editorials. We would like to acknowledge the support and contributions of the sponsoring patient and professional societies, as well as the summit participants. We also thank 3M and their partners for supporting the summit through an educational grant. We look forward to hearing of successes and additional ideas based on our new charge of E 3 -driven interdisciplinary communication and collaboration. Page 11

12 Suggested additional reading: 1. Lingard, L., et al., Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg, (1): p. 12-7; discussion Haynes, A.B., et al., A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med, (5): p de Vries, E.N., et al., Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med, (20): p Haynes, A.B., et al., Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf, (1): p Davenport, D.L., et al., Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg, (6): p Nundy, S., et al., Impact of preoperative briefings on operating room delays: a preliminary report. Arch Surg, (11): p Mazzocco, K., et al., Surgical team behaviors and patient outcomes. Am J Surg, (5): p Beldi, G., et al., Impact of intraoperative behavior on surgical site infections. Am J Surg, (2): p Neily, J., et al., Association between implementation of a medical team training program and surgical mortality. JAMA, (15): p Author Affiliations: E. Patchen Dellinger: University of Washington Medical Center (Seattle, WA.) Richard P. Dutton: Anesthesia Quality Institute (Park Ridge, IL.) Steven Gordon: Cleveland Clinic Foundation (Cleveland, OH.) Charlotte L. Guglielmi: Beth Israel Deaconess Medical Center (Boston, MA.) Lisa Spence Huber: Anderson Hospital (Maryville, IL.) Kathleen Kohut: NCH Healthcare System (Naples, FL.) Acknowledgements: Writing and editorial assistance were provided by Steven D. Walker, M.S., Fleishman-Hillard Inc. This support was funded by 3M. References: 1 Gawande, Atul. The checklist manifesto: how to get things right. Metropolitan Books, New York, NY, Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; Cardo D, et al. Moving toward elimination of healthcare-associated infections: a call to action. Infect Control Hosp Epidemiol 2010;31: Accessed Sept Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention, March Berríos-Torres, SI. Surgical Site Infection (SSI) Toolkit Slide Deck. Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Anderson DJ, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. Inf Control and Hosp Epidemiol 2008; 29 (suppl 1):s51-s61. 8 Klevens RM, et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, Public Health Reports 2007;22: Page 12

13 9 Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health care-associated infections. Am J Infect Control : Accessed Sept Martone WJ, Nichols RL. Recognition, prevention, surveillance, and management of surgical site infections: introduction to the problem and symposium overview. Clin Infect Dis. 33 Suppl :S Page 13