The Role of the Surgical Champion in Quality Improvement (QI): From the ACS NSQIP SAR to Reducing SSI Joe Sharma, MD Associate Professor of Surgery Emory University School of Medicine
A New Surgical Champion Becoming a SC Reviewing the SAR Presenting/Discussing the SAR Frequent meetings with SCR s Pursuing Quality Improvement
2011 Houston we have a problem
Quality Improvement and SC Where do you start? Infection Control Infectious Disease OR leadership Surgeons Residents Nursing Best Practice SSI guidelines from ACS-NSQIP Target : Is this a group vs. individual issue? Start small or go big
Factors associated with QI Longer participation Frequent use of data Close contact with data collectors
Skills for SC in Quality Improvement Setting vision and goals Communication Coaching Constructive environment Working with and through others Earn Trust
Multidisciplinary Team Invitees Surgeons Nursing Anesthesiologists OR environmental team Surgical Clinical Reviewers Quality officials Residents Infection Control Statistician Guru of processes
Wound Infection Group WIG at EUH Anesthesia Preadmit OR General Surg Onc Vascular Urology Plastics Surgery WIG Nursing Periop OR Floor Office of Quality Admin Support Statistician Coordinator CDC Liason Facilities Coders
WIG Goals Implement standardized protocols to reduce surgical site infections at Emory University Hospital by 40% and move to an O/E ratio of 1 in NSQIP by Q4 2015. Develop a Wound Infection Prevention Process (W.I.P.P.) with colorectal surgery as test of change.
Colorectal Surgeon s survey Evaluate practice patterns of all colorectal surgeons Seek input Examine elements of WIPP present in current practice Provides a platform for improvement Elements need minor vs. major overhaul
OR Nursing Survey Concern about prepping without sterile gloves. Making sure padding being placed in the correct areas for long cases and having nerve damage. Not changing gloves during dirty cases and changing instruments during change of services. General to Plastics etc Problem with time. rush, rush, rush. Improve hand washing, sterile technique, and less people in the room. It seems people (the surgeons, residents) are in such a hurry. It concerns me because mistakes are made when you rush and don t take time for safety. Surgeons I work with never wait 3 minutes after prep.
Composite Compliance of Individual SSI Elements in May 2013 % Compliance 100 90 80 70 60 50 40 30 20 10 0 Good: 80% Fair: 30-79% Poor: 30% WIPP Bundle Elements
Audit Results Good(>80% of patients), Fair(31-79%) and Poor(<30%) May 2013 October 2013 May/June 2014 Good 8/15 10/15 11/15 Fair 5/15 4/15 3/15 Poor 2/15 1/15 1/15 # of elements with >90% compliance # of elements with <30% compliance May 2013 October 2013 May/June 2014 3 6 6 2 1 1
Compliance per Colorectal case Procedure Ioban Wound Protectors New Gloves? New Gowns? New Instruments/ Closing pan Colectomy Y N Y N Y Colectomy Y Y Y N Y Colectomy Y Y Y N Y Colostomy Y N Y N N Colostomy Y Y N N Y Colectomy Y N Y N N Appendectomy Y N Y N Y Colectomy Y Y Y N Y Colectomy Y Y Y N Y Colectomy Y Y Y Y Y Colectomy Y Y Y Y Y Colectomy Y Y Y N Y Colostomy Y Y Y N Y Colostomy Y Y Y N Y Colostomy Y N Y N Y Colectomy Y Y Y N Y Colectomy Y Y Y N Y Compliance 100% 71% 94% 12% 88%
Compliance to Elements of the Colorectal Checklist 100 90 80 70 60 50 40 30 20 10 0 May-13 Oct-13 Jun-14 * p-value < 0.05
Colorectal Surgery SSI Reduction 2013 2011
SSI Trend at EUH in Colorectal Surgery NSQIP SAR s 2010-2014 SSI % 20 18 16 14 12 10 8 6 4 2 0 WIG Colorectal WIPP Observed Expected
You don t always win! Patient Temperature Percent of Patients 100 90 80 70 60 50 40 30 20 10 0 % Patients with T>36 in OR % Patients with T>36 in PACU May-13 Oct-13 Jun-14
Be a Coach! Review deficits with practitioners in groups M&M, Surgical Performance Day, QI conference Less threatening It s a system issue, not personal Always have solutions or action plans Provide resources for improvement Let a group organize the improvement plan Be prepared for individuals to challenge NSQIP SAR s and data
Emails Quality Improvement Conference Healthcare Leadership/ Board Meetings M&M Posters/Billboards Failures are part of the process What works and what does not? Celebrate Success!
Expansion of WIPP Vascular Surgery WIPP Colorectal Surgery Hepato-pancreaticobiliary Surgery Urology GI Surgery Gynecology- Oncology
1.5 1.4 1.3 1.2 1.1 1 0.9 0.8 0.7 0.6 0.5 Reduction in SSI rates at EUH 2010-2014 Overall SSI Rate at EUH WIG Number of potential SSI avoided 2013 28 2014-62 O/E Ratio
Cost Savings with a reduction in SSI For 62 patients who did not get a SSI Low estimate = $647,466 High estimate = $1,578,272 Cost of WIPP bundle $272 per patient Quality FTE <0.5
Values of a successful mentor (SC) Professionalism focuses on accountability and honesty, and a good mentor is open with his or her mentees and accepts responsibility for his or her charges professional growth and success. Excellenceis necessary for the mentor to act as a role model for his or her mentees and to promote the highest quality of patient care. Innovationand creative thinking are requisite skills for the mentor who wants to fully lead his or her mentees in new directions and forge a better future. Introspection consists of self-improvement and self-assessment, qualities that an active listener and mentor must possess to lead by example. Inclusionis centered on the active engagement of both the mentor and the mentee and encompasses productive collaboration aimed at harnessing collective intelligence and creativity. Presidential Address at the 2013 Clinical Congress, Carlos A. Pellegrini, MD, FACS
Trust Takes time Verify data Don t react to blips Act when ready Aim small, miss small An attitude of education
Issues you will face with WIPP Criticisms NSQIP is a sample of the data Not adequate data in NSQIP Pathology, Suture type, anastomosis type My patients are different Inadequate staffing Lack of established QI processes Apathy
Acceptance of the process
Issues not addressed Weekly time commitment for SC How to learn the OR/system processes? How long will it take to see results?
Acknowledgements John Sweeney (Chair, Department of Surgery ) Colorectal Surgeons John Galloway, Charlie Staley, Jahnavi Srinivasan Patrick Sullivan & Virginia Shaffer Operating Room Nursing Leadership Cheryl Castleberry & Kathy Galloway Lou Bottoms Infectious Disease Jay Varkey& J. Steinberg Quality Team Sebastian Perez Amy Newell (SCR)& Judy Lewis(SCR) AvinaGoel& Nate Spell Anesthesia Arnold Berry & Beth Duggan Surgery Admin Anesthesia WIG Support Nursing
More Work to Do!!! Wound Infection Prevention Process