surgical infection prevention collaborative northwest · 2019-11-28 · surgical infection...
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HANDBOOKFebruary 2003
Surgical Infection PreventionCollaborative Northwest
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AcknowledgmentsMany organizations and individuals contributed to the development of this handbook andthe Surgical Infection Prevention Collaborative Northwest. We would like to recognizethe following organizations and individuals for providing direction, funding, andexpertise.
The Oklahoma Foundation for Medical Quality, Inc., in collaboration with theCenters for Disease Control and Prevention (CDC) provided valuable assistance inidentifying the quality measures for this Collaborative.
The Collaborative Experience Project: Surgical Infection Prevention, a nationalCollaborative involving hospital and quality improvement organization (QIO) staff fromacross the country, provided the model for the work of this Collaborative. Slightimprovements/revisions have been made to the model due to information about changesimplemented by participating teams and “lessons learned.”
The Institute for Healthcare Improvement (IHI) developed the Collaborative learningmethodology with colleagues from Associates in Process Improvement. IHI and QualisHealth worked with a panel of clinical experts (see below) to develop the charter, changeconcepts, and measurement strategy for this Collaborative.
Qualis Health and OMPRO, not-for-profit quality improvement organizations, jointlysponsor this Collaborative through their contracts with the Centers for Medicare &Medicaid Services.
A panel of experts worked with the national Collaborative (Collaborative ExperienceProject) leadership and faculty to develop the framework for this Collaborative, whichhas been updated slightly based on the experiences of participating teams. Much gratitudeto those who provided clinical expertise:
Ramon Berguer, MDAssociate Professor of Surgery at UC DavisStaff Surgeon, VA Northern California Health Care Systems
George Blike, MDAnesthesiology DepartmentDartmouth Hitchcock Medical Center
Dale Bratzler, DO, MPHClinical CoordinatorOklahoma Foundation for Medical Quality, Inc.
Cynthia Brennan, PharmD, MHAAssistant Director, Ambulatory Pharmacy ServicesHarborview Medical Center
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David Classen, MD, MSAssociate Professor of Medicine, University of UtahFirst Consulting Group
E. Patchen Dellinger, MDChief, Division of General SurgeryUniversity of Washington Medical Center
Peter Houck, MDGovernment Task Leader for National Surgical Infection Prevention ProjectCenters for Medicare & Medicaid Services
Michael Leonard, MDDirector of Patient SafetyKaiser Permanente of Colorado
David Musson, MDResearch Associate, Human Factors Research ProjectUniversity of Texas at Austin
Stanley Pestotnik, MS, RPhPresident and CEOTheradoc
Carol Petersen, RN, BSN, MAOM, CNORPerioperative Nursing SpecialistAssociation of Perioperative Registered Nurses
Stuart Schrader, RN, MHA, CNORDirector, Surgical ServicesEvergreen Healthcare
This material was prepared by Qualis Health and OMPRO under a contract with the Centers for Medicare & Medicaid Services(CMS). The contents presented do not necessarily reflect CMS policy.
7SOW-WA/ID-SIP-03-02 (QH-0607 01/03) 7SOW-OR-SIP-02-02
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ContentsAbout This Handbook....................................................................................................... 1
Getting Started .................................................................................................................. 3Overview ......................................................................................................................... 3Schedule .......................................................................................................................... 4Checklist of Pre-work Activities..................................................................................... 5
Instructions for Completing Pre-work Activities........................................................... 71. Collaborative Charter .................................................................................................. 72. Forming a Team .......................................................................................................... 73. Completing a Memorandum of Understanding........................................................... 94. Scheduling a Pre-work Call ...................................................................................... 105. Obtaining Internet Access ......................................................................................... 106. Registering and Arranging for Travel, Lodging ....................................................... 107. Developing an Aim Statement .................................................................................. 118. Defining a Pilot Population....................................................................................... 139. Defining Measures .................................................................................................... 1310. Collecting Baseline Data......................................................................................... 1411. Preparing a Storyboard............................................................................................ 16Pre-work Activities Worksheet ..................................................................................... 17
Collaborative Charter..................................................................................................... 21Charter........................................................................................................................... 21Mission.......................................................................................................................... 21Goals ............................................................................................................................. 22Problem Statement ........................................................................................................ 22Methods......................................................................................................................... 24Expectations .................................................................................................................. 24References ..................................................................................................................... 26Recommended Reading ................................................................................................ 29
Change Package............................................................................................................... 31
Measurement Strategy.................................................................................................... 35
Glossary of Terms and Concepts ................................................................................... 44
Collaborative Leadership ............................................................................................... 51
SIP Collaborative Northwest Handbook 1
About This HandbookThe purpose of this handbook is to provide you with background and referenceinformation on the Collaborative and to help you prepare for a successful start to thisexciting year of quality improvement.
Getting Started contains an overview of the Collaborative, a schedule of major eventsand periods, and a checklist of pre-work activities—tasks your team should accomplishbefore the first learning session on March 20–21, 2003.
The section on Completing Pre-work will walk your team step-by-step throughpreparing for the first learning session.
The Collaborative Charter contains the mission and rationale for this Collaborativealong with a description of the methods that will be used and lists of Collaborativeexpectations—what your team can expect from the Collaborative and what theCollaborative expects from your team.
The Change Package contains a variety of strategies for preventing surgical infection.You will refer to it throughout the Collaborative.
The Measurement Strategy section provides you with data definitions for the requiredmeasures and provides teams with optional measures, and it describes the data that yourteam will collect to monitor your progress during the Collaborative.
A Glossary of Terms and Concepts and a list of Collaborative Leadership will alsoserve as references throughout the Collaborative.
In addition, please find included with this handbook a detailed Calendar of Activitiesand Events and a list of recommended antibiotics from the Centers for Medicare &Medicaid Services.
SIP Collaborative Northwest Handbook 3
Getting StartedThis section provides you with an overview of the Collaborative, a schedule of activities,and a list of pre-work activities—tasks for you to accomplish before the first learningsession.
OverviewA Collaborative is a systematic approach to healthcare quality improvement in whichhospital teams or other healthcare providers test and measure practice innovations, thenshare their experiences in an effort to accelerate learning and widespread implementationof best practices.
History of Collaboratives In 1995, the Institute for Healthcare Improvement held the first BTS Collaborative, andsince then, more than 700 teams from over 465 U.S. and Canadian healthcareorganizations have participated in BTS Collaboratives. IHI has conducted 26Collaboratives and has begun training other organizations to facilitate Collaborativesmodeled after their BTS Collaboratives.
This CollaborativeThe Surgical Infection Prevention Collaborative Northwest will involve hospital teamsfrom Idaho, Oregon, and Washington working together for 13 months to individually testsystem changes aimed at preventing surgical infections and to collectively share learning.
Collaborative Events and Working TimesFour components of the Collaborative are pre-work activities, learning sessions, actionperiods, and the outcomes congress. Pre-work is the period between receipt of thishandbook and Learning Session 1, March 20–21, 2003. During this time, the hospitalteam has several important tasks to accomplish. These tasks are listed later in this sectionand described in detail in the following section.
Learning sessions are the major interactive events of the Collaborative. Through plenarysessions, small-group discussions, and team meetings, attendees have the opportunity to
• learn from faculty and colleagues,
• receive individual coaching,
• gather knowledge on the subject matter and on process improvement,
• share experiences and collaborate on improvement plans, and
• problem-solve barriers to improving care.
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Action periods are the time between learning sessions. During action periods, your teamwill work within your organization to test and implement changes aimed at preventingsurgical infections. Teams will share the results of their improvement efforts in briefmonthly reports and also participate in shared learning through an electronic mailing list(e-mail list), monthly conference calls, and a Web site. Participation in action periods isnot limited to those who attend learning sessions; we encourage and expect theparticipation of other team members and supporters in the hospital.
An outcomes congress where teams will publicly share their findings and celebrate theirachievements will take place April 1–2, 2004.
ScheduleThe sequence of events for the Collaborative is as follows:
Pre-work February–March, 2003
Learning Session 1 March 20–21, 2003
Action Period 1 March–June, 2003
Learning Session 2 June 19–20, 2003
Action Period 2 June–November, 2003
Learning Session 3 November 17–18, 2003
Action Period 3 November 2003–March 2004
Outcomes Congress April 1–2, 2004
Please also see the attached Calendar of Activities and Events. It provides a moredetailed schedule which includes conference calls and due dates for senior leader reports,monthly reports your team will submit to a senior leader in your organization and to thee-mail list your team will join as part of the Collaborative.
Each team is expected to participate in monthly conference calls with the Collaborativeleadership. The first conference call is scheduled for April 24, 2003, one month after thefirst learning session. The Calendar of Activities and Events provides the dates of all theconference calls for the duration of the Collaborative. All calls will occur at 2 PM pacifictime, 3 PM mountain time.
To connect to the teleconferences, call 1-888-632-5950 and ask for the Surgical InfectionPrevention call with host Lynn Masciarotte.
Getting Started
SIP Collaborative Northwest Handbook 5
Checklist of Pre-work ActivitiesTo prepare for Learning Session 1, each participating hospital needs to complete thefollowing pre-work activities:
� 1. Read the Collaborative charter.
� 2. Form a team.
� 3. Sign a Memorandum of Understanding with Qualis Health (if your hospital is inWashington or Idaho) or with OMPRO (if your hospital is in Oregon).
� 4. Schedule a pre-work call with the Collaborative leadership from your state.Washington hospitals contact: Kathryn Bunt, Qualis Health, 206-364-9700, ext. 2259.
Idaho hospitals contact: Jane Burgman, Qualis Health, 208-389-5035.
Oregon hospitals contact: Lynn Masciarotte, OMPRO, 503-279-0100.
� 5. Obtain Internet access (if needed) for accessing the Collaborative e-mail list.
� 6. Register and arrange for travel to the learning sessions.
� 7. Develop an aim statement.
� 8. Define (or identify) a pilot population.
� 9. Define measures.
� 10. Begin to collect baseline data.
� 11. Prepare a storyboard for Learning Session 1.
The next section of this handbook contains instructions for completing pre-workactivities.
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Instructions for CompletingPre-work ActivitiesThe following pages provide information about how to complete each pre-work activity.A worksheet to help you complete pre-work activities follows.
1. Collaborative CharterPlease read the Collaborative charter, which is the next section of this handbook. Thecharter defines the Collaborative mission, summarizes the evidence that will direct yourwork, outlines methods that your team will use to achieve the mission, and lists whatteams can expect from the Collaborative leadership as well as what the leadership expectsof teams.
2. Forming a TeamHaving an appropriate and effective team is a key component of successful improvementefforts. Choose your team members based on their knowledge of, involvement with, andenthusiasm for the systems and processes that you will work to improve.
Each hospital needs to form a team to test and implement system changes related to theprevention of surgical infection. Four to ten members is a typical size for the team.However, not all team members will need to travel to the learning sessions. Teams shouldinclude people from departments and work areas that will be affected by the changes, toensure that the team understands the system it is trying to redesign and to promote buy-infor the changes.
In the national Surgical Infection Prevention Collaborative, lessons learned included theimportance of having both a surgeon and anesthesiologist on the team as co-clinicalchampions. Your “at home” team may include other vital team members such as nursingstaff (circulating, preoperative, surgical, and postoperative), medical records staff,infection control staff, etc.
Selecting team leadersWhen forming your team, you will need to fill four leadership roles: senior leader, systemleader, clinical champion, and day-to-day leader. The system leader, clinical champion,and day-to-day leader represent the team at the learning sessions and the outcomescongress, and they share their learning with other members of the team. It is occasionallypossible for a single person to fill more than one leadership role, depending on theorganization. Team members will report progress to a senior leader at the hospital whooften attends only the second learning session and the outcomes congress. Ideal teammembers are described below.
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Senior leaderThe ideal senior leader
• has ultimate authority to allocate the time and resources to achieve the team’s aim,
• has administrative authority over all areas affected by the changes the team will testand implement, and
• will champion the spread of successful changes throughout the organization.
Examples of senior leaders include a vice president, CEO, or senior director. The seniorleader is encouraged to attend all learning sessions and the outcomes congress and isexpected to at least attend the second learning session and the outcomes congress.
System leaderThe ideal system leader
• has direct authority to allocate the time and resources to achieve the team’s aim,
• has direct authority over the particular systems affected by the changes the team willtest and implement, and
• will champion the spread of successful changes throughout the department or servicearea.
An example of a system leader would be the administrative (or operational) vicepresident (or director) of the surgical services or perioperative department. The systemleader attends all learning sessions and the outcomes congress.
Clinical championsThe ideal clinical champions
• are practicing providers (both a surgeon and anesthesiologist) who are opinion leadersand are respected by peers,
• understand the processes of care,
• have good working relationships with colleagues and the day-to-day leader, and
• want to drive improvements in the system.It is essential to have clinical champions on the team. At least one clinical championshould attend each learning session and the outcomes congress.
Day-to-day leaderThe ideal day-to-day leader
• drives the project, ensuring that cycles of change are tested, implemented, anddocumented,
• coordinates communication between the team and the Collaborative,
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� oversees data collection, and
� works effectively with the clinical champion.The day-to-day leader should understand how changes will affect systems and shouldhave the time to keep the project moving forward. The day-to-day leader is typically fromthe QI department of the hospital but could also be a perioperative staff nurse or infectioncontrol nurse. The day-to-day leader attends all learning sessions and the outcomescongress.
Other Team MembersIn addition to team leaders, the team includes members from hospital departmentspotentially affected by system changes related to surgical infection prevention. Thesemembers learn about the Collaborative from team leaders and participate inimplementation at the hospital. Potential team members include
� infection control practitioners,
� perioperative personnel,
� surgeons,
� anesthesiologists,
� information specialists, and
� medical records personnel.
Checklist for selecting team membersAn effective team has members who work well together and who have a combination ofskills, styles, and competencies. An effective team has members who
� are leaders,
� are team players,
� have specific skills and technical proficiencies relevant to prevention of surgicalinfection,
� possess excellent listening skills,
� communicate well verbally,
� are problem-solvers,
� are motivated to improve current systems and processes, and
� are creative, innovative, and enthusiastic.
3. Completing a Memorandum of UnderstandingThe purpose of the Memorandum of Understanding (MOU) is to specify theresponsibilities of participating teams and Collaborative sponsors. The MOU is signed by
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the person in your hospital with contract-signing authority. Please work with theCollaborative contact in your state to complete an MOU. In Washington contact KathrynBunt, 206-364-9700, ext. 2259; in Idaho contact Jane Burgman, 208-389-5035; inOregon contact Lynn Masciarotte, 503-279-0100.
4. Scheduling a Pre-work CallContact your QIO to schedule a pre-work call with the Collaborative leadership fromyour state.
Washington hospitals contact: Kathryn Bunt, Qualis Health, 206-364-9700, ext. 2259.
Idaho hospitals contact: Jane Burgman, Qualis Health, 208-389-5035.
Oregon hospitals contact: Lynn Masciarotte, OMPRO, 503-279-0100.
The pre-work call is an opportunity for you to ask additional questions and for theCollaborative leadership to help ensure that your team is ready for Learning Session 1and that the content for Learning Session 1 will address the most common questions andconcerns from participants.
Before the call, your team should have reviewed the Collaborative Handbook and begunthe pre-work activities. The call can typically be completed in a half hour.
5. Obtaining Internet AccessWe strongly urge participants who do not have access to e-mail to subscribe to anInternet service provider for the duration of the Collaborative. Obtaining Internet accessis necessary for teams to have access to the electronic mailing list, or e-mail list, for theCollaborative. The Collaborative leadership and hospital team members will use the listto distribute information and tools, ask questions and receive replies, and conductongoing discussions of changes tested, barriers encountered, and lessons learned. At leastone member from each team must join the e-mail list and take responsibility fordistributing information to the rest of the team; however, we encourage all team membersto join the list. Information on how to join the e-mail list will be available at the firstlearning session.
6. Registering and Arranging for Travel, LodgingTeam leaders represent the team at the learning sessions and the outcomes congress, andthey share their learning with other members of the hospital team. The senior leadertypically plans to attend the second learning session (June 19–20, 2003) and the outcomescongress (April 1–2, 2004). The system leader, a clinical champion, and the day-to-dayleader should attend all learning sessions and the outcomes congress.
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RegisteringPrior to registering for the individual learning sessions, teams must first complete theMemorandum of Understanding (see #3 above) and submit the $1800 participation fee,which covers the cost of three team members attending the three learning sessions. Uponsubmitting the MOU, teams register for each learning session at the Collaborative Website: www.ompro.org/sip-nw. Note: teams must register for each session separately.
Arranging for lodgingThe Collaborative learning sessions and the outcomes congress will be held in differentlocations as follows:
Learning Session 1 March 20–21, 2003 Portland, ORLearning Session 2 June 19–20, 2003 Seattle, WALearning Session 3 November 17–18, 2003 Boise, IDOutcomes Congress April 1–2, 2004 Site TBA
To arrange for lodging for Learning Session 1, call the Sheraton Portland Airport Hotel at1-800-808-9497 or 503-281-2500. To receive the group rate, you must identify yourselfas an attendee of the SIP Collaborative. The deadline to receive the group rate is March6th.
To arrange for lodging for Learning Session 2, call the DoubleTree Hotel Seattle Airportat 1-800-222-8733 or 206-246-8600. Ask for the Surgical Infection PreventionCollaborative group rate.
To arrange for lodging for Learning Session 3, call the Grove Hotel in Boise, 1-800-325-4000 or 208-333-8000. Ask for the Surgical Infection Prevention Collaborative grouprate.
7. Developing an Aim StatementThe present Collaborative is modeled after the IHI Breakthrough Series Collaboratives,which use the Model for Improvement, a “trial-and-learn” approach to qualityimprovement. The Model for Improvement couples three fundamental questions withplan-do-study-act (PDSA) cycles:
1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in an improvement?
The first question is answered in an aim statement. An aim statement is a concise writtenstatement describing what the team expects to accomplish in the Collaborative; itprovides guidance for the team’s specific improvement efforts. The aim statementensures that team activities align with the strategic goals of the team’s organization.
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Involving senior leadership in developing an aim statement can help teams ensure supportfor their work.
An example of an aim statement consistent with the goals of this Collaborative is asfollows:
To improve the care of patients undergoing surgery at General Hospital, we willredesign practice to better prevent surgical site infections. The number of surgicalsite infections identified during routine inpatient surveillance of patients whohave undergone surgery will be cut by half. 100% of eligible surgical patients willreceive appropriate prophylactic antibiotics. 100% of eligible surgical patientswill receive the prophylactic antibiotic within one hour before surgical incisiontime. To ensure that our efforts to prevent infection do not lead to undesirableantibiotic resistance levels, 100% of prophylactic antibiotics delivered prior tosurgery will be discontinued within 24 hours after surgery. Changes to improvethe delivery of prophylactic antibiotics will be tested for the patients of twosurgeons (collectively approximately 50 patients per month). Effective changeswill be spread to the remaining surgical staff at the hospital within one year aftereffective changes have been identified.
In setting your aim, be sure to
Involve senior leaders. Senior leaders must align the aim with strategic goals of theorganization. They must also provide for support personnel and resources frominformation systems, finance and reimbursement, medical affairs, etc. Senior leadersare also responsible for leading the spread of the results from the pilot populationacross the organization. Senior leaders are also responsible for leading the spread ofthe results from the pilot population across the organization.
Base your aim on data or organizational needs. Examine data within yourorganization. Refer to the Collaborative charter and focus on issues that matter atyour hospital.
State the aim clearly and use numerical goals. Teams make better progress whenthey have an unambiguous, specific aim. Setting numerical targets clarifies the aim,helps create tension for change, and directs measurement. For example, an aim to“ensure that 100% of eligible patients will have their blood glucose level monitoredsuch that it is not greater than 200 mg/dL” will be more effective than an aim to“improve blood glucose monitoring.”
There will be time to refine your work at the first learning session and time during theyear to complete work on the aim statement.
Having a measurement and tracking system in place is the answer to the second question:How will we know that a change is an improvement? Continue reading for moreinformation on how to select a pilot population for which four required and two to fouroptional measures will be tracked over the course of the Collaborative.
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Finally, the changes that will result in improvements are contained within the changepackage (see page 31). This change package was tested on a national level and has beenmodified based on the experience of 56 hospitals from across the country.
8. Defining a Pilot PopulationOne important way to accelerate quality improvement in your hospital is to test possiblesystem changes with a small subset of patients (a pilot population). If changes appear toimprove care, you can then spread the changes to the rest of your patients.
For surgical infection prevention, the easiest way to define a pilot population is to beginby identifying particular surgeons who will test changes. For example, if two of the threesurgeons at your hospital are willing to test and implement changes during theCollaborative, the patients seeing those two surgeons in a given month could representyour pilot population for that month. Note: it is important to recruit surgeons andanesthesiologists who are willing to test changes. If all three surgeons’ patients areincluded and only two surgeons make changes, the performance data will be diluted bythe third, non-participating surgeon.
Hospitals should select initial pilot populations based on internal infection data and/orbased on the following suggested surgical procedures: coronary artery bypass grafts(CABG); cardiac, colon, hip and knee arthroplasty; abdominal and vaginal hysterectomy;or selected vascular surgery procedures. Ideally, the surgeons and anesthesiologists youchoose should interact with between 50 and 100 patients undergoing surgery in a givenmonth. Improvements can be seen with less than 100 patients, particularly regardingprocess measures; however, small numbers may make it difficult to see changes in thenumber of cases between surgical site infections.
9. Defining MeasuresSee Measurement Strategy for more details (page 35). Measuring performance during theCollaborative will enable the team to evaluate the impact of changes it makes to improvethe delivery of care to patients undergoing surgery. Performance measurement is not anend in itself. Measurement should be designed to accelerate improvement, not slow itdown.
Each team will monitor progress on four required measures and two to four additional, or“optional,” measures selected by the team.
Required measuresThe required measures address an outcome of care, processes of care, and the potentialimpact on competing, or balancing, system priorities (for example, prevention of resistantstrains of bacteria or control of costs):
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Outcome measure
Number of surgical cases between each surgical site infection
The required outcome measure (the number of surgical cases between identifiedinfections) is a proxy measure identified by the expert panel that IHI convened inDecember 2001. Similar measures have been used in previous Collaboratives. If thehospital is already calculating an infection rate for the pilot population, we encourage youto continue to track that data as an optional measure. When numbers of infections aresmall (e.g., 1% or less), staff may not be motivated to improve care; in fact, providersmay feel good about this data. However, if providers are presented with a number eachmonth telling them how many cases it has been since the last surgical infectionprevention, there is a heightened awareness.
Process measures
Percent of surgical cases with prophylactic antibiotics started within one hourprior to surgical incision
Percent of surgical cases in which appropriate antibiotic was selectedaccording to adopted guidelines
Balancing measure
Proportion of patients who received prophylactic antibiotics whose antibioticswere discontinued within 24 hours after surgery
Optional measuresEach team will specify two to four additional measures that are important to the team;examples include measures related to normothermia, glucose control, oxygenation,avoiding shaving the surgical site, and other basic prevention strategies. Teams shouldconsider outcome measures as well as process measures and should clearly define thenumerator and denominator for their measures (including the type of surgeries that willbe involved).
A complete description of the measures and associated statistics, data collection methods,and corresponding Collaborative goals can be found beginning on page 35.
10. Collecting Baseline DataHospitals are encouraged to collect baseline data on required and optional measuresbefore Learning Session 1. The pre-work activities worksheet (page 17) andMeasurement Strategy section include suggestions for places to begin gathering baselinedata. This will vary based on the measures selected and possibly the pilot population. Theprocess of collecting baseline data may help the team to identify which measures mightbe the most important and feasible for their hospital.
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SIP Collaborative Northwest Handbook 15
Note: Intense data collection for baseline is not necessary, nor recommended. Capturingbaseline data from the previous month’s patients is sufficient. However, if you are a smallhospital, you may wish to collect three to six months of baseline data for the outcomemeasure.
Many hospitals conduct retrospective review for quality improvement projects. This canbe a very time consuming activity. We encourage teams to identify systems in whichprospective data collection may occur. A data collection tool for capturing the numeratorand denominator data for the required measures and any optional measures should beused.
Senior leader reportBeginning in May 2003, each hospital will be expected to prepare a monthly reporttracking the team’s progress on the selected measures and documenting the systemchanges tested during that month. The audience for the report is the senior leadership atthe hospital. Each hospital also shares the report with other Collaborative participants,faculty, and the QIO for their state (Qualis Health or OMPRO). More information aboutthe senior leader report (templates, tools, etc.) will be distributed at the first learningsession.
Annotated run chartThe minimum standard for monitoring the progress of your team throughout theCollaborative is an annotated run chart of each of the required measures and the optionalmeasures that you selected. Data points should be plotted monthly on a run chart andsubmitted with senior leader reports. The following run chart is one example ofappropriate presentation of a measure for the Collaborative:
Percent of Patients Receiving Appropriate Antibiotic
CB
A0
102030405060708090
100
M ay-03 Jul-03 Sep-03 Nov-03 Jan-04 M ar-04 M ay-04
Perc
ent o
f Pat
ient
s
tracking goalMonth
A: Systematic documentation of antibiotic administration on every patient chart. B: Developed guidelines and order sets for prophylactic antibiotics specific to the surgical site, based onnational guidelines and local consensus.C: Pharmacy standardized process to ensure timely delivery of appropriate antibiotic to the holding area orOR.
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16 SIP
Suggested contteam name,brief descripdraft aim stadraft descripdraft list of many baseline
anddescription
Future storyboaPDSA cycleyour progretools you haother learnin
Bring photos, figmaterials.
We’ll provide bo
Annotations on the run chart should include changes that are being evaluated orimplemented, as well as other circumstances that could impact service levels. A tool forproducing run charts will be provided at Learning Session 1.
11. Preparing a StoryboardAt each learning session, your team willbe provided with a 30″ x 40″ foam-coreboard, pushpins, tape, an easel, andother supplies, so that your team cancreate a storyboard to present what ithas accomplished and learned so far.Storyboards help create an environmentconducive to sharing and learning fromthe experiences of others.
At the first learning session in March,your storyboard will be a way tointroduce your team to the otherCollaborative participants. Thestoryboard is an opportunity to havesome fun and show the unique characterof your hospital and your team.
The storyboard should be clear andconcise. The audience for storyboardsconsists of other hospital teams, theCollaborative leadership, observers, and faculty who areyour aim, and your work.
Your Storyboardents for your first storyboard: with team members and their titles;tion of your hospital;tement;tion of your pilot population;easures; data that you have collected so far;
of progress so far.
rds will highlights,ss on measures,ve created, andg that might interest other teams.
ures, colored paper, and other creative
ard, pushpins, and a team sign.
Have fun!
Collaborative Northwest Handbook
not familiar with your facility,
Pre-work Activities Worksheet
SIP Collaborative Northwest Handbook 17
Pre-work Activities WorksheetThe purpose of this worksheet is to facilitate your pre-work and to help you prepare for aconference call with the Collaborative leadership. You are not required to turn in thisworksheet.
1. General information
Name of hospital _____________________________________________________
State _______________________________________________________________
2. Team members (Name) (Title)
Senior leader ________________________________________________________
System leader ________________________________________________________
Day-to-day leader_____________________________________________________
Clinical champion ____________________________________________________
Clinical champion ____________________________________________________
Other team members __________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3. Working draft of aim statement
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18 SIP Collaborative Northwest Handbook
4. Definition of pilot population
Please describe your pilot population (i.e., the surgeon(s) and type(s) of surgeriesfor which you will test changes). Your pilot population will ideally include at least100 surgeries per month.
5. Working list of measures selected
For additional information, please refer to the Measurement Strategy section.
Required measures:
1. Number of surgical cases between each surgical site infection.
2. Percent of surgical cases with prophylactic antibiotics started within 0–1 hourprior to surgical incision.
3. Percent of surgical cases in which appropriate antibiotic was selected according toadopted guidelines.
4. Proportion of patients who received prophylactic antibiotics whose antibioticswere discontinued within 24 hours after surgery.
Potential issues in collecting data for the required measures:
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SIP Collaborative Northwest Handbook 19
Optional measures selected:
Select between two and four. Pick from measurement strategy or generate your own.
1. _________________________________________________________________
2. _________________________________________________________________
3. _________________________________________________________________
4. _________________________________________________________________
Potential issues in collecting data for the optional measures selected:
6. Does my hospital currently track an infection rate by any means, and ifso, how?
7. Baseline data collected so far
Could include any of the following, as available:
a. Overall hospital surgical infection rate:
b. In an average month, our hospital performs ______ surgeries.
c. In an average month, the surgeons we have selected for our pilot team collectivelyperform approximately _______ surgeries.
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20 SIP Collaborative Northwest Handbook
d. A retrospective audit of ____ charts indicated that we have the followingproportions on the required process measures:
____% of cases had an appropriate prophylactic antibiotic given
____% of cases had the prophylactic antibiotic hung within one hour of surgery
____% of cases had the prophylactic antibiotic administered for no more than 24hours after surgery
e. Currently, the average number of surgeries between cases in which an infection isidentified is _______.
f. A retrospective audit of ____ charts in which a surgical infection was identifiedindicated that the following proportions of infections were potentiallypreventable:
____% of cases with identified infections did not have an appropriateprophylactic antibiotic
____% of cases with identified infections did not have the prophylactic antibioticbegun within one hour of surgery
g. Additional baseline data we collected and how we collected it:
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Collaborative CharterThe Collaborative charter includes the mission and goals for the Collaborative, a problemstatement that describes opportunities to prevent surgical site infections, a methodssection that describes how the Collaborative works and what models will be used; asection on expectations, and references and recommended reading. The charter,measurement strategy, and change package (described in following sections) weredeveloped by the Institute for Healthcare Improvement (IHI) and Qualis Health, with apanel of clinical experts.
CharterThe purpose of the Collaborative is to improve the quality of care delivered to patientsduring surgery in a cost-effective manner through system redesign using proven,evidence-based practices. The goal, as reflected in process measures, is that 100 percentof eligible patient populations receive appropriate and timely prophylactic antibiotics.Hospitals are also strongly encouraged to select additional prevention-related measuresrelated to normothermia, glucose control, oxygenation, hair removal, and other infection-prevention procedures to improve redesign of their systems of care.
MissionThe mission of this Collaborative is to achieve, in 13 months, a breakthroughimprovement in surgical infection prevention. The primary emphasis of thisCollaborative is to create systems of care that dramatically improve the prevention ofsurgical infections. The Collaborative will take a preventive approach, which includes,but is not limited to, preventing SSIs. Hospitals will prevent infections by implementing asystem-wide model of care, which focuses on assuring the safe delivery of care on a day-to-day basis for patients undergoing surgery. The mission encourages hospitals toredesign systems within a safety culture.
A safety culture can be defined as “the product of individual and group values, attitudes,competencies, and patterns of behavior that determine the commitment to, and style andproficiency of, an organization’s health and safety programs.”1 Hospitals with a positivesafety culture are characterized by communications founded on mutual trust, by sharedperceptions of the importance of safety, and by confidence in the efficacy of preventivemeasures.
The Collaborative faculty will help each hospital achieve this mission and their hospital-specific aim. The faculty will support the teams in meeting the Collaborative goals bysharing the best available scientific knowledge on creating safe systems in clinical areasand by teaching and applying methods for organizational change.
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22 SIP Collaborative Northwest Handbook
GoalsThe main goals of the Collaborative are to
1. Double the number of surgical cases between SSIs.
2. Achieve 100% compliance with appropriate selection and timing of prophylacticantibiotic administration:100% of patients will have antibiotic prophylaxis initiated within one hour prior
to incision*,100% of patients will be given prophylactic antibiotics consistent with published
guidelines, and100% of patients given prophylactic antibiotics will have those antibiotics
discontinued within 24 hours after surgery.
* See Measurement Strategy section for exceptions, which include patients receivingvancomycin, with tourniquets or those undergoing C-sections. The measurementstrategy also includes a list of optional measures. Teams will have additionaloptional measures related to other surgical infection prevention strategies.
Problem StatementAmericans rely on their healthcare system for the maintenance and improvement ofhealth, which often involves care in the hospital setting. Although most patients believethat the American healthcare system provides the highest quality and safest care in theworld, it is estimated that four out of every one hundred hospitalized patients in theUnited States suffers a serious adverse event, many of which are avoidable. In theInstitute of Medicine report To Err is Human it is estimated that between 44,000 and98,000 deaths per year result from adverse events.2 In comparison, there areapproximately 45,000 deaths yearly from auto accidents.
Sixty-nine percent of adverse events and deaths in healthcare are due to an error inmanagement and thus are potentially preventable. Dr. Lucian Leape and colleagues havedescribed these types of errors, which include diagnostic failures, treatment errors, errorsin prevention, and others including communication failure and equipment failure.3 Someof these errors lead to perioperative infections, a major cause of patient injury, mortality,and healthcare cost. An estimated 2.6 percent of nearly 30 million operations arecomplicated by surgical site infections (SSIs) each year.
Established in 1970, the CDC’s National Nosocomial Infections Surveillance (NNIS)system monitors reported trends in nosocomial infections in participating US acute-carehospitals. According to the NNIS system reports, SSIs are the third most frequentlyreported nosocomial infection, accounting for 14–16% of all nosocomial infectionsamong hospitalized patients.4 Surgical site infections are a common complication of care,occurring in 2–5% of patients after clean extra-abdominal operations (e.g., thoracic andorthopedic operations) and in up to 20% of patients undergoing intra-abdominalprocedures.5-10 Among surgical patients, SSIs were the most common nosocomial
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SIP Collaborative Northwest Handbook 23
infection, accounting for 38% of all such infections. When surgical patients withnosocomial SSI died, 77% of the deaths were reported as related to the infection, and themajority (93%) were serious infections involving organs or spaces accessed during theoperation.11 Cruse estimated that an SSI increased a patient’s hospital stay byapproximately ten days and cost an additional $2,000 in 1980.12,13 There are more recentstudies, including a 1992 analysis by Martone, which corroborate an increase in length ofstay and cost (7.3 additional postoperative hospital days and $3,152 in extra charges) inpatients with SSIs.14-16 If a hospital with an annual surgical volume of 10,000 operationscould reduce their 300 SSIs by half, this would result in an average annual cost savings ofapproximately $450,000, based on 1992 cost estimates. Deep SSIs involving organs orspaces are associated with even greater increases in hospital stays and costs.17,18
An estimated 40–60% of SSIs are preventable with appropriate use of prophylacticantibiotics.11, 19-21 Overuse, under use, improper timing, and misuse of antibiotics occursin 25–50% of operations.22-26 A large number of hospitalized patients develop infectionscaused by Clostridium difficile, and 16% of this type of infection in surgical patients canbe attributed to inappropriate prophylaxis use alone.27 Inappropriate use of broadspectrum antibiotics or prolonged courses of prophylactic antibiotics puts all patients ateven greater health risks due to the development of antibiotic-resistant pathogens. Inaddition to the proper use of prophylactic antibiotics and good surgical technique, otherfactors under the control of the operative team have been demonstrated to affectsignificantly the risk of SSI.11 These other factors include preventing hypothermia duringthe procedure,28 maintaining high levels of inspired oxygen,29 controlling serum glucosewithin certain limits,30-32 avoiding shaving the operative site,33-37 and other basicprevention strategies.38 All of these preventive measures provide opportunities forimprovement in most hospitals.
Although the primary focus of the Collaborative work is SSIs, infections in patientsundergoing surgery are not limited to those that involve the surgical site. Other types ofinfections occurring in patients undergoing surgery include, but are not limited to,infections of centrally inserted venous access lines for perioperative monitoring, urinarytract infections, and pneumonia.
Effective surgical infection prevention and harm reduction therefore require redesigningsystems with safety in mind.39 The fundamental law of improvement is this: every systemis perfectly designed to achieve exactly the results it gets. In order to attain a new level ofperformance in safety, there must be a new system. This applies to all forms ofperformance—such as selection, timing, and duration of antimicrobial prophylaxis;thermoregulation; oxygen tension; glucose control; hair removal and other basicprevention strategies. Some healthcare organizations have succeeded in creating new andsafer systems for SSIs.40 Major opportunities still exist to reduce the incidence of surgicalinfections, create safer care for patients requiring surgery and a more satisfactory workenvironment for healthcare workers, and reduce costs and improve efficiency.
Reducing surgical infections while minimizing antibiotic resistance remains a challengeto many healthcare institutions. Healthcare providers are faced with the additionalchallenge of trying to integrate new evidence-based infection prevention strategies, such
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24 SIP Collaborative Northwest Handbook
as perioperative glycemic control, into practice. Enlightened management teams,regulatory agencies, health plan providers and purchasers, and medical associations needto provide the support required to create a culture of patient safety in our healthcaresystems. With this support, informed, activated hospital teams can be empowered tomake key changes to their subsystems (e.g., surgical units) and to incorporate safetyconsiderations into their everyday work.
MethodsEach hospital is expected to develop an aim statement (a statement on what the teamexpects to accomplish during the Collaborative) that includes specific goals relating topreventing surgical infections. Hospitals should begin by working initially within aspecific surgical population (pilot population) or with one or two surgeons (clinicalchampions) and anesthesiologist(s) (also clinical champions). The ultimate goal is tospread the improvements to other populations and throughout the entire system. Hospitalsshould select initial pilot populations based on internal infection data and/or based on thefollowing suggested surgical procedures: coronary artery bypass grafts (CABG), cardiac,colon, hip and knee arthroplasty, abdominal and vaginal hysterectomy, or selectedvascular surgery procedures. To facilitate learning during the Collaborative, hospitalsshould try to identify a pilot population that is expected to result in at least 100 surgeriesper month or 100% of surgical cases for selected surgeries listed above.
Both process and outcome measurement strategies will be used to assess organizationalprogress toward achieving Collaborative goals. Hospitals will learn an improvementstrategy that includes breakthrough goals and a method to develop, test, and implementchanges in their systems. Hospitals will be expected to collect well-defined data thatrelate to their aim at least monthly and to plot these data over time for the duration of theCollaborative. An annotated time series or run chart will be used to assess the impact ofchanges.
The Collaborative faculty will aid hospitals in capitalizing on the learning andimprovement from the focused project by simultaneously coaching senior leaders inhospitals to develop a system for spreading improvement to other surgical populations,sites, units, or surgical staff.
ExpectationsThe Collaborative faculty will
• provide information on subject matter, application of that subject matter, and methodsfor process improvement, both during and between learning sessions;
• offer coaching to teams;
• provide an electronic mailing list (e-mail list) and other communication venues forshared learning;
• assess team progress and provide feedback to teams monthly;
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SIP Collaborative Northwest Handbook 25
• plan and implement the four face-to-face meetings (three learning sessions and anoutcomes congress);
• maintain and safeguard the confidentiality of privileged data or information—whetherwritten, photographed, or electronically recorded and whether generated or acquiredby the team—which can be used to identify an individual patient, practitioner,hospital, facility, health plan, or patient population.
Hospitals are expected to
• perform pre-work activities as outlined in section II of the handbook;
• connect the goals of the Collaborative work to a strategic initiative in the hospital;
• provide a senior leader to sponsor and actively support the team;
• provide the resources to support the team, including resources necessary for learningsessions and staff time to devote to this effort (approximately one FTE for theduration of the Collaborative);
• participate in each learning session (participation by all core team members is highlyrecommended, and participation in the congress that concludes the Collaborative isdesirable);
• identify the performance measures that the team is going to target, including therequired performance measures related to appropriate antibiotic prophylaxis;
• plan, design and implement plan-do-study-act (PDSA) improvement cycles to meetthe targeted performance measures;
• submit monthly reports to the team’s senior leader and Collaborative faculty,identifying progress and PDSA cycles implemented;
• create storyboards for presentation at each learning session;
• share information with the Collaborative, including details of changes made and datato support these changes, both during and between learning sessions; maintain andsafeguard the confidentiality of privileged data or information—whether written,photographed, or electronically recorded and whether generated or acquired by theteam—which can be used to identify an individual patient, practitioner, hospital,facility, health plan, or patient population.
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26 SIP Collaborative Northwest Handbook
References1. Nolan TW. System changes to improve patient safety. BMJ. 2000;320:771-773.
2. Institute of Medicine. To Err is Human. Washington DC: The National AcademyPress, 1999.
3. Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury.Quality Review Bulletin. 1993;19:144–149.
4. Emori TG, Gaynes RP. An overview of nosocomial infections, including the role ofthe microbiology laboratory. Clin Microbiol Rev. 1993;6(4):428–442.
5. Delgado-Rodriguez M, Sillero-Arenas M, Medina-Cuadros M, Martinez-Gallego G.Nosocomial infections in surgical patients: comparison of two measures of intrinsicpatient risk. Infect Control Hosp Epidemiol. 1997;18:19–23.
6. Horan TC, Culver DH, Gaynes RP, Jarvis WR, Edwards JR, Reid CR. Nosocomialinfections in surgical patients in the United States, January 1986-June 1992. NationalNosocomial Infections Surveillance (NNIS) System. Infect Control Hosp Epidemiol.1993;14:73–80.
7. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions ofnosocomial surgical site infections, 1992: a modification of CDC definitions ofsurgical wound infections. Infect Control Hosp Epidemiol. 1992;13:606–608.
8. Horan TC, Emori TG. Definitions of key terms used in the NNIS System. Am JInfect Control. 1997;25:112–116.
9. Wallace WC, Cinat M, Gornick WB, Lekawa ME, Wilson SE. Nosocomialinfections in the surgical intensive care unit: a difference between trauma andsurgical patients. Am Surg. 1999;65:987–990.
10. Scheel O, Stormark M. National prevalence survey on hospital infections in Norway.J Hosp Infect. 1999;41:331–335.
11. Mangram AJ, Horan TC, Pearson ML, et al.: Guideline for prevention of surgicalsite infection, 1999. Hospital Infection Control Practices Advisory Committee. InfectControl Hosp Epidemiol. 1999;20:250–278; quiz 279–280.
12. Cruse PJ. Wound infection surveillance. Rev Infect Dis. 1981;4(3):734–737.
13. Cruse PJ, Foord R. The epidemiology of wound infection: a 10-year prospectivestudy of 62,939 wounds. Surg Clin North Am. 1980;60(1): 27–40.
14. Martone WJ, Jarvis WR, Culver DH, Haley RW. Incidence and nature of endemicand epidemic nosocomial infections. In: Bennett JV, Brachman PS, eds. HospitalInfections. 3rd ed. Boston: Little, Brown and Co; 1992. p. 577–96.
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15. Boyce JM, Potter-Bynoe G, Dziobek L. Hospital reimbursement patterns amongpatients with surgical wound infections following open-heart surgery. InfectControl Hosp Epidemiol.1990;11(2):89–93.
16. Poulsen KB, Bremmelgaard A, Sorensen AI, Raahave D, Petersen JV. Estimatedcosts of postoperative wound infections. A case-control study of marginal hospitaland social security costs. Epidemiol Infect. 1994;113(2): 283–295.
17. Vegas AA, Jodra VM, Garcia ML. Nosocomial infection in surgery wards: acontrolled study of increased duration of hospital stays and direct cost ofhospitalization. Eur J Epidemiol. 1993;9(5):504–510.
18. Albers BA, Patka P, Haarman HJ, Kostense PJ. Cost effectiveness of preventiveantibiotic administration for lowering risk of infection by 0.25%. [German].Unfallchirurg. 1994;97(12):625–628.
19. Platt R, Zaleznik DF, Hopkins CC, et al.: Perioperative antibiotic prophylaxis forherniorrhaphy and breast surgery. N Engl J Med. 1990;322:153–160.
20. Dellinger EP, Gross PA, Barrett TL, et al.: Quality standard for antimicrobialprophylaxis in surgical procedures. Infectious Diseases Society of America. ClinInfect Dis. 1994;18:422–427.
21. Page CP, Bohnen JMA, Fletcher JR, et al.: Antimicrobial prophylaxis for surgicalwounds: Guidelines for clinical care. Arch Surg. 1993;128:79–88.
22. Gyssens IC, Geerligs IE, Dony JM, et al.: Optimising antimicrobial drug use insurgery: an intervention study in a Dutch university hospital. J AntimicrobChemother. 1996;38:1001–1012.
23. Gyssens IC, Geerligs IE, Nannini-Bergman MG, et al.: Optimizing the timing ofantimicrobial prophylaxis in surgery: an intervention study. J Antimicrob Chemother.1996;38:301–308.
24. Silver A, Eichorn A, Kral J, et al.: Timeliness and use of antibiotic prophylaxis inselected inpatient surgical procedures. The Antibiotic Prophylaxis Study Group. AmJ Surg. 1996;171:548–552.
25. Finkelstein R, Reinhertz G, Embom A: Surveillance of the use of antibioticprophylaxis in surgery. Isr J Med Sci. 1996;32:1093–1097.
26. Houck PM, Bratzler DW. Personal communication.
27. Crabtree TD, Pelletier SJ, Gleason TG, Pruett TL, Sawyer RG. Clinicalcharacteristics and antibiotic utilization in surgical patients with Clostridiumdifficile-associated diarrhea. Am Surg. 1999;65:507–511.
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28 SIP Collaborative Northwest Handbook
28. Kurz A, Sessler DI, Lenhardt R: Perioperative normothermia to reduce the incidenceof surgical-wound infection and shorten hospitalization. Study of Wound Infectionand Temperature Group [see comments]. N Engl J Med. 1996;334:1209–1215.
29. Greif R, Akca O, Horn EP, et al.: Supplemental perioperative oxygen to reduce theincidence of surgical-wound infection. Outcomes Research Group [see comments].N Engl J Med. 2000;342:161–167.
30. Dellinger EP: Preventing surgical-site infections: the importance of timing andglucose control. Infect Control Hosp Epidemiol. 2001;22:604–606.
31. Latham R, Lancaster AD, Covington JF, et al.: The association of diabetes andglucose control with surgical-site infections among cardiothoracic surgery patients.Infect Control Hosp Epidemiol. 2001;22:607–612.
32. Furnary AP, Zerr KJ, Grunkemeier GL, Starr A: Continuous intravenous insulininfusion reduces the incidence of deep sternal wound infection in diabetic patientsafter cardiac surgical procedures [see comments]. Ann Thorac Surg. 1999;67:352–360; discussion 360–352.
33. Olson MM, MacCallum J, McQuarrie DG: Preoperative hair removal with clippersdoes not increase infection rate in clean surgical wounds. Surg Gynecol Obstet.1986;162:181–182.
34. Horgan MA, Piatt JH, Jr.: Shaving of the scalp may increase the rate of infection inCSF shunt surgery. Pediatr Neurosurg. 1997;26:180–184.
35. Balthazar ER, Colt JD, Nichols RL: Preoperative hair removal: a random prospectivestudy of shaving versus clipping. South Med J. 1982;75:799–801.
36. Ko W, Lazenby WD, Zelano JA, et al.: Effects of shaving methods andintraoperative irrigation on suppurative mediastinitis after bypass operations. Annalsof Thoracic Surgery. 1992;53:301–305.
37. Pomposelli JJ, Baxter JK, 3rd, Babineau TJ, et al.: Early postoperative glucosecontrol predicts nosocomial infection rate in diabetic patients. JPEN J ParenterEnteral Nutr. 1998;22:77–81.
38. Guideline for Prevention of Surgical Site Infection, 1999. Available athttp://www.cdc.gov/ncidod/hip/ssi/ssi.pdf.
39. Reason J. Human error: models and management. BMJ. 2000;320:768–770.
40. Classen DC, Evans RS, Pestotnik SL, Burke JP. The timing of prophylacticadministration of antibiotics and the risk of surgical-wound infection. N Engl J Med.1992; 326:281–286. ty. BMJ. 2000;320:771–773.
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Recommended Reading1. Burke JP. Maximizing appropriate antibiotic prophylaxis for surgical patients: an
update from LDS Hospital, Salt Lake City. Clin Infect Dis. 2001;33(Suppl):78–83.
2. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timingof prophylactic administration of antibiotics and the risk of surgical-wound infection.N Engl J Med. 1992;326:281–286.
3. Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobialprophylaxis in surgical procedures. The Infectious Diseases Society of America.Infect Control Hosp Epidemiol. 1994;15:182–188.
4. Gaynes RP, Culver DH, Horan TC, Edwards JR, Richards C, Tolson JS. Surgical siteinfection (SSI) rates in the United States, 1992–1998: the National NosocomialInfections Surveillance System basic SSI risk index. Clin Infect Dis.2001;33(suppl):69–77.
5. Greif R, Akca O, Horn EP, Kurz A, Sessler DI. Supplemental perioperative oxygen toreduce the incidence of surgical- wound infection. Outcomes Research Group. N EnglJ Med. 2000;342:161–167.
6. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions ofnosocomial surgical site infections, 1992: a modification of CDC definitions ofsurgical wound infections. Am J Infect Control. 1992;20:271–274.
7. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidenceof surgical-wound infection and shorten hospitalization. Study of Wound Infectionand Temperature Group. N Engl J Med. 1996;334:1209–1215.
8. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline forprevention of surgical site infection, 1999. Hospital Infection Control PracticesAdvisory Committee. Infect Control Hosp Epidemiol. 1999;20:250–278; quiz 279–280.
9. Page CP, Bohnen JM, Fletcher JR, McManus AT, Solomkin JS, Wittmann DH.Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care. ArchSurg. 1993;128:79–88.
10. University of California at San Francisco–Stanford University Evidence-basedPractice Center. Chapter 20, Prevention of Surgical Site Infections, of EvidenceReport/Technology Assessment No. 43, Making Health Care Safer: A CriticalAnalysis of Patient Safety Practices, AHRQ Publication No. 01-EO58: Agency forHealthcare Research and Quality. Available at www.ahrq.gov/clinic/ptsafety onMarch 8, 2002.
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L/m
in fr
esh
gas
flow
in th
e no
n-in
tuba
ted
patie
nt fo
r 2 h
ours
• D
esig
n ed
ucat
iona
l tra
inin
g pr
ogra
ms
for p
osto
pera
tive
staf
f
Avoi
d sh
avin
g op
erat
ive
site
• R
emov
e al
l raz
ors
from
ope
ratin
g ro
om•
Perfo
rm h
air r
emov
al w
hen
nece
ssar
y w
ith c
lippe
rs ri
ght b
efor
e su
rger
y•
Esta
blis
h pr
otoc
ol fo
r whe
n an
d ho
w to
rem
ove
hair
in a
ffect
ed a
reas
•
Prov
ide
patie
nt e
duca
tion
and
mat
eria
ls o
n ap
prop
riate
hai
r rem
oval
tech
niqu
es to
pre
vent
sha
ving
at h
ome
Basi
c pr
even
tion
stra
tegi
es*
(Bas
ed o
n or
gani
zatio
nal s
elf-
asse
ssm
ent o
f adh
eren
ce to
prac
tice)
*Cat
egor
y IA
CD
CR
ecom
men
datio
ns
• Ex
clud
e pa
tient
s w
ith p
rior i
nfec
tions
• St
op p
atie
nt to
bacc
o us
e pr
ior t
o su
rger
y•
Appl
y st
erile
dre
ssin
g fo
r 24–
48 h
r•
Show
er w
ith a
ntis
eptic
soa
p•
Prov
ide
posi
tive
pres
sure
ven
tilat
ion
in O
R w
ith a
t lea
st 1
5 ai
r cha
nges
/hr
• Ke
ep O
R d
oors
clo
sed
• U
se s
teril
e in
stru
men
ts•
Wea
r a m
ask
• C
over
hai
r•
Prep
are
skin
with
app
ropr
iate
age
nt•
Wea
r ste
rile
glov
es; d
oubl
e-gl
ove
• M
aint
ain
shor
t nai
ls; r
emov
e ar
tific
ial n
ails
• H
andl
e tis
sue
gent
ly•
Ensu
re th
at s
urge
ons/
staf
f cle
an h
ands
with
app
ropr
iate
age
nts
and
met
hods
• D
elay
prim
ary
clos
ure
for h
eavi
ly c
onta
min
ated
wou
nds
• Ex
clud
e in
fect
ed s
urge
ons
• U
se c
lose
d su
ctio
n dr
ains
(whe
n us
ed)
SIP
Col
labo
rativ
e N
orth
wes
t Han
dboo
k35
Mea
sure
men
t Str
ateg
yTh
e fo
llow
ing
tabl
e lis
ts re
quire
d an
d op
tiona
l mea
sure
s tha
t tea
ms c
an se
lect
or a
dapt
. Tea
ms c
an a
lso
deve
lop
new
mea
sure
s bas
edon
the
issu
es th
at a
re o
f mos
t int
eres
t and
impo
rtanc
e to
thei
r hos
pita
l. Th
ere
are
thre
e ty
pes o
f mea
sure
s: o
utco
me
mea
sure
s, pr
oces
sm
easu
res,
and
bala
ncin
g m
easu
res.
The
tabl
e be
low
pro
vide
s def
initi
ons o
f eac
h ty
pe o
f mea
sure
. Als
o pr
ovid
ed o
n pa
ge 4
3 is
asa
mpl
e da
ta c
olle
ctio
n to
ol. T
his t
ool w
ill a
lso
be a
vaila
ble
elec
troni
cally
on
the
e-m
ail l
ist.
Mea
sure
Stat
istic
Def
initi
onD
ata
Col
lect
ion
Appr
opria
teC
olla
bora
tive
Goa
ls
Out
com
e M
easu
res
(Mea
sure
s of
cha
nge
[or l
ack
of c
hang
e] in
the
wel
l-bei
ng o
f a d
efin
ed p
opul
atio
n re
late
d to
an
inte
rven
tion.
Impr
ovem
ent i
n ou
tcom
e m
easu
res
refle
cts
the
heal
th s
tatu
s of
the
patie
nt, w
here
as p
roce
ss m
easu
res
refle
ct th
e ca
re d
eliv
ery
to th
e pa
tient
. Im
prov
emen
t in
outc
ome
mea
sure
s ha
s a
dire
ct e
ffect
on
mor
talit
y an
d m
orbi
dity
.)
O1.
Num
ber o
f sur
gica
l cas
esbe
twee
n su
rgic
al s
ite in
fect
ions
(SSI
s)
(Req
uire
d)
Num
ber o
f sur
gica
l cas
es b
etw
een
each
SSI
Infe
ctio
ns a
cqui
red
in th
e ho
spita
lby
a s
urgi
cal p
atie
nt a
t the
sur
gica
lsi
te. S
SI m
ay b
e of
thre
e ty
pes:
• su
perfi
cial
inci
sion
al•
deep
inci
sion
al•
orga
n or
spa
ce in
fect
ion
Cre
ate
syst
em to
cap
ture
dat
apr
ospe
ctiv
ely
on 1
00%
of p
atie
nts
in th
e pi
lot p
opul
atio
n
May
requ
ire re
visi
ng ru
n ch
arts
cont
inuo
usly
Dou
ble
num
ber o
fsu
rgic
al c
ases
bet
wee
nSS
Is
Mea
sure
men
t Stra
tegy
36SI
P C
olla
bora
tive
Nor
thw
est H
andb
ook
Mea
sure
Stat
istic
Def
initi
onD
ata
Col
lect
ion
Appr
opria
teC
olla
bora
tive
Goa
ls
Proc
ess
Mea
sure
s (W
hat i
s do
ne to
, for
, with
, or b
y de
fined
indi
vidu
als
or g
roup
s as
par
t of t
he d
eliv
ery
of s
ervi
ces.
)
P1. P
erce
nt o
f sur
gica
l cas
es w
ithon
-tim
e pr
ophy
lact
ic a
ntib
iotic
adm
inis
tratio
n
(Req
uire
d)
• N
= n
umbe
r of p
atie
nts
with
prop
hyla
ctic
ant
ibio
tics
with
inon
e ho
ur p
rior t
o su
rgic
alin
cisi
on (s
ee “E
xcep
tions
” to
the
right
)•
D =
num
ber o
f sur
gica
l cas
esw
ith d
ocum
ente
d an
tibio
ticad
min
istra
tion
time
and
time
ofsu
rgic
al in
cisi
on
• An
tibio
tic s
tarte
d m
eans
adm
inis
tratio
n ha
s be
gun
but
is n
ot n
eces
saril
y co
mpl
eted
• C
ases
in w
hich
tim
e of
antib
iotic
adm
inis
tratio
n or
time
of s
urgi
cal i
ncis
ion
is n
otdo
cum
ente
d sh
ould
be
excl
uded
from
the
num
erat
oran
d de
nom
inat
or•
Exce
ptio
ns: (
1) w
ithin
two
hour
s if
patie
nt re
ceiv
ing
vanc
omyc
in d
ue to
bet
a-la
ctam
alle
rgy,
(2) p
atie
nts
with
tour
niqu
ets
need
to h
ave
all a
ntib
iotic
adm
inis
tratio
nco
mpl
eted
bef
ore
the
tour
niqu
et is
infla
ted
and
with
in o
ne h
our p
rior t
osu
rgic
al in
cisi
on a
nd (3
)pa
tient
s un
derg
oing
C-s
ectio
nsh
ould
rece
ive
the
antib
iotic
as
soon
as
the
umbi
lical
cor
d is
clam
ped
Cre
ate
syst
em to
cap
ture
dat
apr
ospe
ctiv
ely
on 1
00%
of p
atie
nts
100%
beg
inni
ng w
ithin
one
hour
prio
r to
surg
ical
inci
sion
(see
“Exc
eptio
ns”
to th
e le
ft)
Mea
sure
men
t Stra
tegy
SIP
Col
labo
rativ
e N
orth
wes
t Han
dboo
k37
Mea
sure
Stat
istic
Def
initi
onD
ata
Col
lect
ion
Appr
opria
teC
olla
bora
tive
Goa
ls
P1-2
. Per
cent
of s
urgi
cal c
ases
with
timin
g do
cum
ente
d
(Opt
iona
l)
• N
= n
umbe
r of p
atie
nts
with
times
doc
umen
ted
• D
= n
umbe
r of s
urgi
cal c
ases
rece
ivin
g pr
ophy
lact
ican
tibio
tics
Prop
ortio
n of
pat
ient
s re
ceiv
ing
apr
ophy
lact
ic a
ntib
iotic
who
hav
ean
tibio
tic a
dmin
istra
tion
time
and
time
of s
urgi
cal i
ncis
ion
docu
men
ted
Cre
ate
syst
em to
cap
ture
dat
apr
ospe
ctiv
ely
on 1
00%
of p
atie
nts
100%
of p
atie
nts
rece
ivin
g pr
ophy
lact
ican
tibio
tics
P2. P
erce
nt o
f sur
gica
l cas
es w
ithap
prop
riate
sel
ectio
n of
prop
hyla
ctic
ant
ibio
tic
(Req
uire
d)
• N
= n
umbe
r of p
atie
nts
rece
ivin
g an
tibio
tic c
onsi
sten
tw
ith a
dopt
ed g
uide
lines
• D
= n
umbe
r of s
urgi
cal c
ases
• Pr
opor
tion
of p
atie
nts
give
nrig
ht a
ntib
iotic
as
dete
rmin
edby
pub
lishe
d gu
idel
ines
• O
rgan
izat
ions
will
adop
t apu
blis
hed
guid
elin
e (C
MS
orot
her)
or a
dapt
a p
ublis
hed
guid
elin
e to
loca
lci
rcum
stan
ces
and
use
this
tode
term
ine
if th
e co
rrect
antib
iotic
was
giv
en to
the
patie
nt•
Not
e: S
ee b
ack
pock
et o
fha
ndbo
ok fo
r CM
Sre
com
men
ded
guid
elin
es
• C
reat
e sy
stem
to c
aptu
re d
ata
pros
pect
ivel
y on
100
% o
fpa
tient
s•
If ev
ents
ver
y ra
re, m
ay u
seth
e nu
mbe
r of c
ases
bet
wee
nin
appr
opria
te s
elec
tion
Achi
eve
100%
com
plia
nce
with
appr
opria
te s
elec
tion
ofpr
ophy
lact
ic a
ntib
iotic
s
P3. P
erce
nt o
f pat
ient
s w
ithpe
riope
rativ
e gl
ucos
e co
ntro
l
(Opt
iona
l)
• N
= n
umbe
r of s
urgi
cal
patie
nts
(all
proc
edur
es)
who
se s
erum
glu
cose
was
cont
rolle
d•
D =
num
ber o
f sur
gica
lpa
tient
s un
derg
oing
car
diac
surg
ery
or n
umbe
r of s
urgi
cal
patie
nts
with
dia
bete
s (a
llpr
oced
ures
)
Alte
rnat
e pr
opos
ed d
efin
ition
ispe
rcen
t of p
atie
nts
with
ser
umgl
ucos
e ≤2
00 m
g/dL
intra
oper
ativ
ely
and
durin
g th
e fir
st48
hou
rs p
osto
pera
tivel
y
Cre
ate
syst
em to
cap
ture
dat
apr
ospe
ctiv
ely
on 1
00%
of p
atie
nts
Achi
eve
100%
com
plia
nce
with
perio
pera
tive
gluc
ose
cont
rol (
alte
rnat
ivel
y,≤2
00 m
g/dL
) dur
ing
the
first
48
hour
s af
ter a
nop
erat
ion
for t
he p
ilot
popu
latio
n
Mea
sure
men
t Stra
tegy
38SI
P C
olla
bora
tive
Nor
thw
est H
andb
ook
Mea
sure
Stat
istic
Def
initi
onD
ata
Col
lect
ion
Appr
opria
teC
olla
bora
tive
Goa
ls
P4. P
erce
nt o
f sur
gica
l pat
ient
s w
ithpe
riope
rativ
e no
rmot
herm
ia
(Opt
iona
l)
• N
= n
umbe
r of s
urgi
cal
patie
nts
with
tem
pera
ture
>36
°C•
D =
num
ber o
f pat
ient
s no
tex
clud
ed fr
om n
orm
othe
rmic
mai
nten
ance
• N
orm
othe
rmia
occ
urs
whe
nte
mpe
ratu
re >
36 °C
• Ex
clus
ion:
pat
ient
s fo
r who
mhy
poth
erm
ia is
del
iber
atel
yso
ught
for t
hera
peut
ic re
ason
s(e
.g.,
hypo
ther
mic
tota
lci
rcul
ator
y ar
rest
)
• R
ecor
d la
st in
traop
erat
ive
tem
pera
ture
(alte
rnat
ivel
y,re
cord
tem
pera
ture
upo
nar
rival
to P
ACU
)•
Cre
ate
syst
em to
cap
ture
dat
apr
ospe
ctiv
ely
on 1
00%
of
patie
nts
100%
for t
hose
not
excl
uded
from
norm
othe
rmic
mai
nten
ance
P5. P
erce
nt o
f sur
gica
l pat
ient
spr
ovid
ed s
uppl
emen
tal O
2pe
riope
rativ
ely
(Opt
iona
l)
• N
= n
umbe
r of p
atie
nts
rece
ivin
g su
pple
men
tal O
2pe
riope
rativ
ely
• D
= n
umbe
r of p
atie
nts
mee
ting
incl
usio
n cr
iteria
Supp
lem
enta
l O2 i
s de
fined
as
(a)
intra
oper
ativ
e FI
O2 >
80%
in th
ein
tuba
ted
patie
nt o
r a n
on-
rebr
eath
ing
face
mas
k at
>12
L/m
infre
sh g
as fl
ow in
the
non-
intu
bate
dpa
tient
and
(b) p
osto
pera
tive
FIO
2>8
0% in
the
intu
bate
d pa
tient
or a
non-
rebr
eath
ing
face
mas
k at
>12
L/m
in fr
esh
gas
flow
in th
e no
n-in
tuba
ted
patie
nt fo
r 2 h
ours
Excl
usio
ns: (
1) a
mbu
lato
ry p
atie
nts
(not
adm
itted
as
inpa
tient
s) a
nd (2
)pa
tient
s w
ith C
OPD
and
evi
denc
efo
r CO
2 ret
entio
n
• C
reat
e sy
stem
to c
aptu
re d
ata
pros
pect
ivel
y on
100
% o
fpa
tient
s•
Team
s m
ight
wan
t to
star
t with
high
-risk
pop
ulat
ion
100%
sur
gica
l pat
ient
sno
t exc
lude
d
Mea
sure
men
t Stra
tegy
SIP
Col
labo
rativ
e N
orth
wes
t Han
dboo
k39
Mea
sure
Stat
istic
Def
initi
onD
ata
Col
lect
ion
Appr
opria
teC
olla
bora
tive
Goa
ls
P6. P
erce
nt o
f sur
gica
l sta
ff w
hoar
e kn
owle
dgea
ble
in s
urgi
cal
infe
ctio
n pr
even
tion
(Opt
iona
l)
• N
= n
umbe
r of s
taff
who
obt
ain
a sc
ore
of 1
00%
on
post
-test
• D
= n
umbe
r of s
taff
surv
eyed
Res
embl
es a
spr
ead
mea
sure
inth
at it
may
be
cum
ulat
ive
by m
onth
Use
sur
vey
afte
r edu
catio
n de
tailin
gsu
rgic
al in
fect
ion
prev
entio
npr
actic
es
100%
of s
urgi
cal s
taff
know
ledg
eabl
e in
sur
gica
lin
fect
ion
prev
entio
n
P7. P
erce
nt o
f pat
ient
s w
ithap
prop
riate
hai
r rem
oval
(Opt
iona
l)
• N
= n
umbe
r of s
urgi
cal
patie
nts
with
hai
r rem
oved
appr
opria
tely
• D
= n
umbe
r of p
atie
nts
requ
iring
hai
r rem
oval
• Ex
clus
ion:
pat
ient
s fo
r who
mha
ir re
mov
al is
not
nec
essa
ry•
Cre
ate
syst
em to
cap
ture
dat
apr
ospe
ctiv
ely
on 1
00%
of
patie
nts
• D
efin
e ap
prop
riate
hai
rre
mov
al fo
r eac
h ty
pe o
fsu
rger
y in
pilo
t pop
ulat
ion
(e.g
., de
pila
tory
may
be
appr
opria
te, c
lippi
ng m
ay b
eap
prop
riate
, usu
ally
sha
ving
isno
t app
ropr
iate
)
Achi
eve
100%
com
plia
nce
with
appr
opria
te h
air r
emov
al
Mea
sure
men
t Stra
tegy
40SI
P C
olla
bora
tive
Nor
thw
est H
andb
ook
Mea
sure
Stat
istic
Def
initi
onD
ata
Col
lect
ion
Appr
opria
teC
olla
bora
tive
Goa
ls
Bal
anci
ng M
easu
res
(Mea
sure
s th
at to
geth
er w
ith th
e se
lect
ed p
roce
ss a
nd o
utco
me
mea
sure
s de
scrib
e a
grea
t sys
tem
of c
are.
The
se m
easu
res
may
be
proc
ess
or o
utco
me
mea
sure
s, a
nd u
sual
ly m
easu
re s
ome
aspe
ct o
f the
sys
tem
that
may
inad
verta
ntly
be
affe
cted
by
chan
ges
in s
peci
fic a
reas
of t
he m
odel
.)
B1. P
erce
nt o
f sur
gica
l pat
ient
s w
hore
ceiv
ed p
roph
ylac
tic a
ntib
iotic
sw
hose
ant
ibio
tics
wer
e di
scon
tinue
dw
ithin
24
hour
s af
ter s
urge
ry
Not
e: th
is m
easu
re li
nked
to c
ost
and
to p
reve
ntio
n of
resi
stan
tst
rain
s of
bac
teria
(Req
uire
d)
• N
= n
umbe
r of p
atie
nts
rece
ivin
g pr
ophy
lact
ican
tibio
tics
who
had
them
disc
ontin
ued
with
in 2
4 ho
urs
• D
= n
umbe
r of p
atie
nts
who
rece
ived
pro
phyl
actic
antib
iotic
s
Dis
cont
inue
d is
def
ined
as
disc
ontin
ued
with
in 2
4 ho
urs
of th
esu
rger
y en
d tim
e
Cre
ate
syst
em to
cap
ture
dat
apr
ospe
ctiv
ely
on 1
00%
of p
atie
nts
100%
of s
urgi
cal p
atie
nts
with
pro
phyl
actic
ant
ibio
tics
disc
ontin
ued
with
in 2
4ho
urs
of th
e su
rger
y en
dtim
e
B2. C
ost p
er s
urge
ry
(Opt
iona
l)
• N
= d
olla
rs a
lloca
ted
tosu
rgic
al a
ccou
ntin
g co
des
per
mon
th•
D =
num
ber o
f sur
gica
l cas
es
No
incr
ease
in d
irect
cos
ts,
or in
crea
se in
dire
ct c
ost i
sle
ss th
an th
e co
st o
f SSI
spr
even
ted
B3. V
olum
e of
sur
gica
l wor
kloa
dpe
r mon
th
(Opt
iona
l)
Num
ber o
f sur
gica
l cas
es p
erm
onth
Surg
ery
defin
ed a
s in
volv
ing
anin
cisi
on a
nd o
ccur
ring
in a
nop
erat
ing
room
Mea
sure
men
t Stra
tegy
SIP
Col
labo
rativ
e N
orth
wes
t Han
dboo
k41
Mea
sure
Stat
istic
Def
initi
onD
ata
Col
lect
ion
Appr
opria
teC
olla
bora
tive
Goa
ls
B4. I
ncid
ence
of r
esis
tant
bac
teria
lst
rain
s
(Opt
iona
l)
1.N
= n
umbe
r of d
iffer
ent r
esis
tant
stra
ins.
If th
e sa
me
stra
in is
isol
ated
sev
eral
tim
es fr
om th
esa
me
patie
nt, i
t sho
uld
only
be
repo
rted
once
. If t
he a
ppar
ently
sam
e st
rain
is is
olat
ed fr
omse
vera
l pat
ient
s, it
sho
uld
bere
porte
d fo
r eac
h pa
tient
.
D =
num
ber o
f sur
gica
l IC
Upa
tient
day
s/10
00 d
ays
2.N
= d
efin
ed d
aily
dos
e
D =
num
ber o
f sur
gica
l IC
Upa
tient
day
s/10
00 d
ays
1.N
umbe
r of r
esis
tant
stra
ins
per
1000
pat
ient
day
s; u
sela
bora
tory
det
erm
inat
ion
ofre
sist
ant s
train
2. D
efin
ed d
aily
dos
e of
ant
ibio
tics
per 1
000
patie
nt d
ays
Labo
rato
ry d
ata
Measurement Strategy
SIP Collaborative Northwest Handbook 43
SSI Prevention Collaborative Data Collection Record Sample
Surgical Case Information:Patient Name: ___________________________________________________________
Patient Medical Record Number #: _____________ Age (in years): _______ Sex: 1 = Male 2 = FemaleDate of Surgery: _________________ Surgical Procedure #1: ____ 1 = Laminectomy without fusion
MM DD YY 2 = Fusion
Time of Incision: ____________________ CRNA: ____________________________
Hair Removal: Clippers Razor None
Prophylaxis Information: (Circle One)Pre-op surgeon antibiotic order on patient’s medical record? 1 = Yes 0 = No 7 = Missing data 9 = UnknownPre-op antibiotic started 0-1 hour before surgery start time? 1 = Yes 0 = No 7 = Missing data 9 = Unknown
Antibiotic doses documented (pre-op, intra-op):____ Dose given:______ Gm or _________mg __________ ___________
H H M M H H M M____ Dose given:______ Gm or _________mg __________ ___________
H H M M H H M M____ Dose given:______ Gm or _________mg __________ ___________
H H M M H H M M0 = None1 = Cefazolin (Kefzol, Ancef)2 = Vancomycin3 = Clindamycin (Cleocin)4 = Nafcillin5 = Cefepine6 = Cefuroxime7 = Other – specify: _______________________8 = Missing data 9 = Unknown
Supplemental Oxygen 1 = Yes 0 = No 3 = Does not apply 7 = Missing data 9 = Unknown
_____Intraoperative FIO2>80% in intubated patient_____Exclusion: Patient with COPD and evidence for CO2 retention
Normothermia_____Last temperature taken prior to leaving OR
Postoperative Antibiotic Order: 1 = Yes 0 = No 3 = Does not apply 7 = Missing data 9 = Unknown
_____Antibiotic ordered (see above)_____Antibiotic ordered to be discontinued within 24 hours after surgery
Other comments:____________________________________________________________________________________
Please place form in infection control box found in PACU. If this form is found onchart, please return to Infection Control Department.
SIP Collaborative Northwest Handbook 44
Glossary of Terms and Conceptsaction periodThe time between learning sessions when teams work on improvement in theirorganizations. They are supported by the Collaborative leadership team and faculty andother Collaborative team members via an e-mail list, a Web site, monthlyteleconferences, and site visits.
aim, or aim statementA written, measurable, and time-sensitive statement of the accomplishments a teamexpects to make from its improvement efforts. The aim statement contains a generaldescription of the work, the pilot population, and the numerical goals.
annotated run chart, or annotated time seriesA line graph showing results of improvement efforts plotted over time. Implementedchanges and other relevant information are noted on the line chart, allowing the viewer toconnect changes and events with specific results. Example:
Percent of Patients Receiving Appropriate Antibiotic
A BC
0102030405060708090
100
M ay-03 Jul-03 Sep-03 Nov-03 Jan-04 M ar-04 M ay-04Perc
ent o
f Pat
ient
s
tracking goalM ont h
A: Systematic documentation of antibiotic administration on every patient chart. B: Developed guidelines and order sets for prophylactic antibiotics specific to the surgical site, based onnational guidelines and local consensus.C: Pharmacy standardized process to ensure timely delivery of appropriate antibiotic to the holding area orOR.
assessment scaleA numerical scale used to assess the progress of participating teams toward reaching theiraim: 1 = forming team, and 5 = outstanding, sustainable improvement. In eachCollaborative, faculty assess teams and also ask them to evaluate their own progressusing this scale. The expected level of attainment by the end of the Collaborative is a 4(significant progress).
balancing measuresOptional measures that track unintended consequences of improvement efforts.
chairThe leader of the Collaborative, usually an expert in the topic.
Glossary
SIP Collaborative Northwest Handbook 45
championAn individual in the organization who believes strongly in quality improvement and iswilling to work with others to test, implement, and spread changes. Teams need at leastone clinical champion. Champions in other disciplines who work on the process areimportant as well.
change conceptA general idea for changing a process, usually developed by an expert panel based onliterature and practical application of evidence. Change concepts are usually at a highlevel of abstraction, but evoke multiple specific ideas for how to change processes.“Simplify,” “reduce handoffs,” and “consider all parties as part of the same system,” areall examples of change concepts.
change ideaAn actionable, specific idea for changing a process. Change ideas can be tested todetermine whether they result in improvements in the local environment. An example ofa change idea is, “Ensure patients are warm (>36oC) by using Bairhugger blanketpreoperatively and then transporting the patient to the OR with the blanket in place.”
change packageA collection of change concepts and key changes.
CollaborativeA systematic approach to healthcare quality improvement in which organizations andproviders test and measure practice innovations, then share their experiences in an effortto accelerate learning and widespread implementation of best practices. Everyoneteaches, everyone learns.
Collaborative leadership and facultyThe small group of experts on the topic who assist the chair and director in developingthe Collaborative and in teaching and coaching participating teams. The Collaborativeleadership and other faculty members generally represent the spectrum of healthcareprofessionals involved in the change process.
Collaborative teamAll individuals from the participating organizations that drive and participate in theimprovement process. A core team of three to four individuals attends the learningsessions, but a larger team of three to six people, often from various disciplines,participates in the improvement process in the organization.
coordinatorStaff person responsible for the day-to-day activities of the Collaborative, includingscheduling conference calls, collecting and disseminating materials, receiving andtracking monthly reports, and managing the e-mail list.
Glossary
46 SIP Collaborative Northwest Handbook
core team membersThe individuals who attend the learning session and fulfill the roles of senior leader,system leader, clinical champion, and day-to-day leader.
cycleSee “PDSA cycle.”
data collection planA specific description of the data to be collected, the interval of data collection, and thesubjects from whom the data will be collected. The plan is included in all senior leaderreports. It emphasizes the importance of gathering samples of data to obtain “justenough” information.
day-to-day leaderThe person on the team who is responsible for driving the improvement process everyday. This person manages the team, arranges meetings, and assures that tests are beingcompleted and that data are collected. This role usually requires 0.25 FTE or more.
directorThe manager of a Collaborative who works with the faculty, teaches and coaches teams,and plans and executes activities at learning sessions and during action periods.
early adopterIn the improvement process, the opinion leader within the organization who brings innew ideas from the outside, tries them, and uses positive results to persuade others in theorganization to adopt the successful changes.
early majority and late majorityThe individuals in the organization who will adopt a change only after it is tested by anearly adopter (early majority) or after the majority of the organization is already using thechange (late majority).
electronic mailing list, or e-mail listA communication system that allows teams to stay connected with the leadership teamand each other during the action periods. Sharing information, getting questionsanswered, and solving problems are all part of e-mail list activity.
handbookPages containing a complete description of the Collaborative, along with what to expectand activities to complete before the first meeting of the Collaborative.
implementationTaking a change and making it a permanent part of the system. A change may be testedfirst and then implemented throughout the organization.
Glossary
SIP Collaborative Northwest Handbook 47
improvement advisorThe expert in process improvement and measurement who assists the chair and directorin guiding the Collaborative’s work and coaching teams.
improvement cycleSee “PDSA cycle.”
ISRefers to the information system of an organization, which is usually the computerizedinformation system.
key change, or process changeA change in a system or process in an organization that may lead to breakthroughimprovement. Key changes are more focused and detailed than change concepts, but theyare not specific to the local environment like change ideas. An example of a key changeis, “Maintain normal body temperature perioperatively.”
late majority and early majoritySee “early majority and late majority.”
learning sessionA two-day meeting during which team members and faculty meet to learn what keychanges are and to learn how to test and implement them, accelerate improvement, andovercome obstacles. Teams leave these meetings with new knowledge, skills, andmaterials that prepare them to make immediate changes.
measureA focused, reportable, unit that will help a team monitor its progress toward achieving itsaim.
Model for ImprovementAn approach to process improvement, developed by Associates in Process Improvement,that helps teams accelerate the adoption of proven and effective changes. The modelincludes use of “rapid-cycle improvement,” successive cycles of planning, doing,studying, and acting (PDSA cycles).
outcomes congressA large public meeting at the end of the Collaborative during which the best practices inthe topic area are presented to others interested in making improvements.
PDSA cycleA structured trial of a process change. Drawn from the Shewhart cycle, this effortincludes the following steps:
plan—a specific planning phase;
do—a time to try the change and observe what happens;
Glossary
48 SIP Collaborative Northwest Handbook
study—sometimes called “check,” an analysis of the results of the trial; and
act—devising next steps based on the analysis.
This PDSA cycle will naturally lead to the “plan” component of a subsequent cycle.PDSA cycles are also called rapid cycles or improvement cycles.
pilot population, or population of focusA designated set of patients who will be tracked to determine whether changes haveresulted in improvements. For this Collaborative, the pilot population will generallyconsist of (1) identifying particular surgeons/anesthesiologists who are interested andexcited about testing changes (e.g., all patients of Dr. Smith and Dr. Jones), or (2)identifying groups of patients undergoing a particular kind of surgery (e.g., all coronaryartery bypass grafts [CABG]). Ideally, the surgeons and anesthesiologists you chooseshould interact with between 50 and 100 patients undergoing surgery in a given month.
population of focusSee “pilot population.”
pre-workThe time before the first learning session when teams prepare for their work in theCollaborative. Pre-work activities include forming a team, registering for the firstlearning session, scheduling initial meetings, preparing an aim statement, defining a pilotpopulation, selecting measures, and populating a registry.
process changeSee “key change.”
rapid cycleSee “PDSA cycle.”
run chartSee “annotated run chart.”
senior leaderThe executive in the organization who supports the team and controls the resourcesemployed in the processes to be changed. The senior leader works to connect the team’saim to the organization’s mission, provides resources for the team, and promotes thespread of the team’s work to other populations.
senior leader reportThe standard format for reporting monthly progress during the Collaborative. Thisconcise report (usually about two pages) includes an aim statement, measures to be used,a data collection plan, a listing of the changes made, the results displayed as run charts,and a self-assessment score. The team prepares the report and sends it to the senior leaderat the organization, in addition to posting it to the e-mail list. The Collaborativeleadership reviews the reports and prepares a summary of all senior leader reports.
Glossary
SIP Collaborative Northwest Handbook 49
spreadThe intentional and methodical expansion of the number and type of people, units, ororganizations using the improvements. The theory and application of spread comes fromthe literature on the concept of Diffusion of Innovation.
storyboardA 30″ x 40″ foam-core board that displays information about a team and its progress andthat is displayed at learning sessions to help create an environment conducive to sharingand learning from the experiences of others. For more information, see the CompletingPre-work section.
system leaderThe core team member who has direct authority to allocate the time and resources toachieve the team’s aim, has direct authority over the particular systems affected by thechange, and will champion the spread of successful changes throughout the department orservice area. The system leader attends all three learning sessions and the outcomescongress.
technical expertThe team member in the organization who has a strong understanding of the process to beimproved and changes to be made. A technical expert may also provide expertise inprocess improvement, data collection and analysis, and team function.
testA small-scale trial of a new approach or a new process. A test is designed to learnwhether the change results in improvement or to fine-tune the change to fit theorganization and patients. Tests are carried out using PDSA cycles
SIP Collaborative Northwest Handbook 51
Collaborative LeadershipCollaborative Chair and Faculty Collaborative DirectorE. Patchen Dellinger, MD
Chief, Division of General Surgery
University of Washington Medical Center
1959 N.E. Pacific Street
Department of Surgery
Box 356410
Seattle, WA 98195–6410
206.543.3682
Lynn Masciarotte, RN, BSN, CPHQ
OMPRO
2020 SW Fourth Avenue, Suite 520
Portland, OR 97201-4960
503.279.0100
Collaborative Improvement Advisor and Faculty Collaborative CoordinatorDonna Daniel, PhD
Qualis Health
10700 Meridian Avenue North, Suite 100
PO Box 33400
Seattle, WA 98133-0400
206.364.9700, ext. 2376
Kathryn Bunt
Qualis Health
10700 Meridian Avenue North, Suite 100
PO Box 33400
Seattle, WA 98133-0400
206.364.9700, ext. 2259
Idaho Improvement Lead Oregon Improvement LeadJane Burgman, RN
Qualis Health
720 Park Blvd., Suite 120
Boise, ID 83712-7756
208.389.5035
Donna Thatcher, RN, CPHQ
OMPRO
2020 SW Fourth Avenue, Suite 520
Portland, OR 97201-4960
503.279.0100
Washington Improvement LeadSusan Hausmann, MS
Qualis Health
10700 Meridian Avenue North, Suite 100
PO Box 33400
Seattle, WA 98133–0400
206.364.9700, ext. 2890