NAME: Mirian Nnah
STUDENT NUMBER: 100780566
Part A:
Topic:
Quality Improvement plan to reduce
surgical site infections at an acute care for
post-surgical patients.
AIM
What is the rationale for this QI project?
Currently Surgical site infections is now the
most common in healthcare associated
infections in post surgical patients. These
infections depend on the type of operation
that was performed by the surgeon, this
triggers 7-11 extra postoperative days in the
hospital; and results in 2-11 times higher
risk of death than noninfected patients.
Unit:
Skel/Musc medicine
unit
Date:
22/10/2022
Who is on your team?
The interprofessional team’s members involved
would include the surgeon, Anesthesiologist,
operating room nurse, surgical tech, physician
assistant, physical therapist, pharmacist, and
social workers.
It is very essential to obtain opinions and views
from the team members above regarding the
problem and the solutions to the problem. The
collaboration of the interprofessional team
Up to 60% of surgical infections can be
members will obtain the insights and then team
prevented. Prevention of this can be done by collaboration is unlocked.
general good hand hygiene. Effective
barriers against the transmission of
infections, before, Durning and after
surgery, the hospital leaders, knowledge and
skill of the surgical team, enough resource,
excellent treatment of the complete patient
admission and monitoring of the patients
after discharge may lead to significant
reduction of surgical site infections, lower
death rates and less expensive health
system.
What is your AIM (ensure your AIM statement is clear, timely, stretchable & value)
the AIM for this is that they would be a reduction in surgical site infections after using the
strategies like building a proper hand hygiene. From 60%-10%. We would reach this goal in
one year.
MEASURES
What will you measure? (consider: outcome, process & balancing measures); consider pre &
post measures.
1. The rate of surgical site incidence after 2 months pf implementing thorough handwashing protocol.
2. Feedback from the interprofessional team members and staff members about the hand
hygiene protocol before, during and after surgery.
3. 95% of clean and clean-contaminated patients with timely propylitic antibiotic
administration.
PROCESS TOOL
Insert your Process tool below:
Process- assessment of current practice and prevention of surgical site infections.
Using the check sheets tool
Bringing the idea of hand- hygiene protocol
Review the relevant literature
Discuss the idea with Management team and staff members.
Assess the whether the protocol; can be easily done
Organize introduction and orientation sessions
Application of the idea using the written protocol
Gather data, resources, and information.
Seek advice and help
Rectifying the mistakes
See hand-hygiene protocol is seen through and followed up with
Keep gathering information and data on surgical site infections on post-surgical patients
Review the data from your QI Process Tool. Based on your analysis of the problem what are
your top three ideas for change?
1. Care planning and interventions label the risk factors with the care plan of the patient.
2. Make agreement upon antibiotic available in the operating room
3. Educate OR staff regarding the importance and reasoning on effective hand- washing
protocols
Which (1) idea would you like to test through a rapid PDSA cycle?
The one idea I would like to test through a rapid PDSA cycle is the Standardized assessment
of surgical site infections risk factors.
Hand- washing protocol.
Since it involves set of intervention as
1. check the dressing for drainage
2. perform hand-hygiene
3. Strict sterile asepsis during dressing changes
4. Monitor the patients vital signs
And risk factors which includes
- Smoking
- Having diabetes
- Having a weak immune system
Being Overweight
- Having a history of other medical problems and diseases.
References
-
Admin. (2020, January 3). Preventing surgical-site infections. American Nurse.
Retrieved October 22, 2022, from https://www.myamericannurse.com/preventingsurgical-site-infections/
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Changes to prevent surgical site infection: IHI. Institute for Healthcare Improvement.
(n.d.). Retrieved October 22, 2022, from
https://www.ihi.org/resources/Pages/Changes/ChangestoPreventSurgicalSiteInfection.asp
x
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Quality standards and CQI. Quality Standards and CQI - Expanded Learning (CA Dept
of Education). (n.d.). Retrieved October 22, 2022, from
https://www.cde.ca.gov/ls/ex/qualstandcqi.asp
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Anderson, D. J., Podgorny, K., Berríos-Torres, S. I., Bratzler, D. W., Dellinger, E. P.,
Greene, L., Nyquist, A.-C., Saiman, L., Yokoe, D. S., Maragakis, L. L., & Kaye, K. S.
(2014, June). Strategies to prevent surgical site infections in Acute Care Hospitals: 2014
update. Infection control and hospital epidemiology. Retrieved October 22, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267723/
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Patient safety metrics: CPSI. Measures: Surgical Site Infections (SSI). (n.d.). Retrieved
October 22, 2022, from
https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/SSImeasurement.aspx
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Mathur, P. (2011, November). Hand hygiene: Back to the basics of infection control. The
Indian journal of medical research. Retrieved October 22, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249958/
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Part B:
PLAN
The purpose of this cycle is to:
The purpose of this cycle is in the
reduction surgical infection after
using the hand hygiene protocol
from a 60%-10%
Develop 
Development of
hand hygiene
strategies and
protocols.
What question do you want to answer?
1.
Is there reduction in surgical
infection after
implementation of hand
hygiene protocol among the
health care workers and
patients.
Implement 
Implementation
of hand hygiene
checklist through
the various
personnel.
What do you think will happen (what are your
predictions?)
After appropriate implementation of the hand
hygiene protocol components, there would be
reduction of surgical infections from the current
rate of 60% -10% in the acute care population.
Plan to collect data to answer your questions:
What data will be
How?
Who? (role)
collected
1. The rate of
Observations
Team Leader,
surgical
and reporting
Manager,
infections
the incidence
hospital
after two
related to
Coordinator
months of
surgical
implementatio infection
n of the hand
hygiene
protocol.
Test 
Testing the
implementation
of hand hygiene
protocol.
When?
Where?
During the
period of two
months.
Musc/Skel 6E
unit.
2. The feedback
of staff and
the
interprofessio
nal team
members
concerning
the
implementatio
n of the hand
hygiene
protocol.
3. Accepting the
hand hygiene
protocol
among the
heath care
workers and
the financial
implementatio
n.
List tasks necessary to set up the test:
What is the task
How?
Surgical site
infections register
update and
maintenance.
Making
maintenance of
the incidences
register.
Who? (role)
When?
Where?
Team Leader,
Hospital
Coordinator.
During the time Musc/Skel 6E
of two months. unit.
DO
What did you observe during the test? Were there any unexpected observations?
Use evidenced based resources to identify what you would expect to observe during the test.
Be sure to cite & reference using APA formatting
Health care providers ensure the use of safe, effective, and ethnical infection prevention and
control measures is an important component of nursing care. This can make them practice
within their scope and know the limits they can work in. To do so, nurses are expected to be
aware of applicable CNO standards, relevant legislation, best practice, and organizational
policies related to infection prevention and control. As outlined by the infection Prevention
and Control Canada, proper hand hygiene is the single most important infection prevention
and control practice, in doing so, nurses provide and promote the best possible patient care. (
College Nurses of Ontario, 2022)
if you had the opportunity to implement your PDSA cycle, What did you observe during the
test? Were there any unexpected observations?
Carrying out the hand hygiene protocol components is obtainable and getting the staff
feedback is positive, the team members were following the hand hygiene protocol.
STUDY
Analyze your data & describe the results? How do the results compare with your predictions?
What did you learn from this cycle?
Use evidenced based resources to identify what data you would expect. Be sure to cite &
reference using APA formatting.
Using the TAP tool developed by the CDC (Centres for Disease Control and prevention), this
data is used for the action to prevent health care associated infections. The TAP strategy
targets the healthcare facilities and specific units in those facilities with disproportionate
burden of HAIs so that gaps in infection can be addressed. These reports are available for
catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream
infections (CLABSI), Clostridioides difficile infections (CDI), and Methicillinresistant Staphylococcus aureus (MRSA). Acute Care Hospitals can run TAP Reports for
CAUTI, CLABSI, CDI, and MRSA; Long Term Acute Care Hospitals are able to run TAP
Reports for CAUTI, CLABSI, and CDI; and Inpatient Rehab Facilities (IRFs) and IRF Units
are able to run TAP Reports for CAUTI and CDI. The TAP Facility Assessment Tools and
TAP Implementation Guides were developed in 2016 and are now available for CAUTI,
CLABSI, and CDI. (Control for Disease Control and Prevention, August 2022)
If you chose to implement your PDSA cycle, analyze your data & describe the results? How
do the results compare with your predictions? What did you learn from this cycle?
There was a reduction in surgical site infections from 60% to 10% after implementing the
hand hygiene protocol, not 13%. It was hard implementing the protocol as we encountered
some feedback and problems in implementing the hand hygiene protocol components because
of the lack of the encouragement and support from the team members. I have learnt to improve
the gaps in implementation, and it is essential to look over the protocol and the PDSA cycle
again.
ACT
Are you ready to implement?
 Yes (I am confident that there is measured improvement, changes have been tested under
different conditions & questions answered).
 No (I have more questions, need to make adjustments and test again, OR risks outweigh
benefits – new ideas are required)
Yes (I am confident that there is a measured improvement and change that have been tested
under different conditions and questions answered).
What is your plan for the next cycle?
In conducting the next cycle with more understanding, more involvement from the team
members, and avaiable resources and education with a systematic approach.
References.
Infection prevention and control. (n.d.). Retrieved November 12, 2022, from
https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/infectionprevention-and-control/
Centers for Disease Control and Prevention. (2022, August 5). The targeted assessment for
prevention (TAP) strategy. Centers for Disease Control and Prevention. Retrieved
November 12, 2022, from https://www.cdc.gov/hai/prevent/tap.html
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