Joint Commission Center for Transforming Healthcare
(CTH)
Cynosure Health Summit
21st May 2012
© Copyright, The Joint Commission
Partnering for Success in
Reducing Surgical Site Infections
2
© Copyright, The Joint Commission
Siew Lee Grand-Clément RN, MSN, CPHQ
Center Project Leader: Surgical Site Infections Collaborative
Joint Commission Center for Transforming Healthcare (CTH)
1. To explain the collaborative working model of the
Joint Commission Center for Transforming
Healthcare.
2. To describe the problem solving methodology used
in reducing Surgical Site Infections.
3. To identify the key stakeholders involved and
describe the process of forming an effective multidisciplinary team.
4. To demonstrate the use of infection control and
prevention practices in driving improvements.
5. To illustrate the roles of nursing in process
improvement initiative.
3
© Copyright, The Joint Commission
Objectives
© Copyright, The Joint Commission
4
Introduction to CTH-Vision
One Vision
5
© Copyright, The Joint Commission
All people always
experience the safest,
highest quality, best-value
health care across all
settings.
Why the CTH was Created
Presents a new approach to address critical
safety and quality problems sought by The
Joint Commission, health care organizations,
patients and their families, physicians and
other clinicians, and other public and private
stakeholders
6
© Copyright, The Joint Commission
Our Mission - Transform health care into a
high reliability industry and to ensure patients
receive the safest, highest quality care they
expect and deserve.
What’s Different About the Center?
Unique approach to improvement:
Center for Transforming Healthcare (CTH)
collaborating with HCOs and hospital leaders
where lean, six sigma are already working
Powerful process improvement tools (RPI)
Engaging industry coupled with reach of TJC
– Leadership Advisory Council Members & Sponsors
– Ability to spread solutions to 19,000+ accredited
health care organizations in US
7
© Copyright, The Joint Commission
– Underlying causes, targeted solutions
– Integrated change management for acceptance and
accountability
8
© Copyright, The Joint Commission
Introduction to CTH-Targeting
Root Causes
 Project 1 – Hand Hygiene Compliance
 Project 2 – Wrong Site Surgery
 Project 3 – Hand Off Communication
 Project 4 – Surgical Site Infections
– With American College of Surgeons
 Project 5 – Preventing Avoidable Heart Failure
Hospitalizations
– With American College of Physicians
 Project 6 – Safety Culture
 Project 7 – Preventing Falls with Injury
 Project 8 – Reducing Sepsis Mortality
 Project 9 – Medication Safety
9
© Copyright, The Joint Commission
Introduction to CTH-Projects
PROJECT #4:
SURGICAL SITE INFECTIONS
Seven participating hospitals:
1. Mayo Clinic, MN
2. Cleveland Clinic, OH
3. Stanford Hospital & Clinics, CA
4. OSF Saint Francis, IL
5. Northwestern Memorial Hospital, IL
6. North Shore LIJ, NY
7. Cedars-Sinai Medical Center, CA
10
© Copyright, The Joint Commission
Collaborate with American College of
Surgeons & NSQIP measurement system
leveraged.
Systematic Approach to Problem Solving
– Surgical Site Infections (1)
To help narrow the scope of the project, the following criteria were used
to identify a specific procedure that:
Is common across different types of hospitals
Has significant complications with an adverse clinical impact
Hospitals have significant opportunities to improve performance
Has high variability in performance across hospitals
11
© Copyright, The Joint Commission
The Center worked with the American College of Surgeons to determine
the scope of the SSI project, since there is a wide range of surgeries
and procedures that can develop SSIs – each with its own unique set of
complications and challenges.
Systematic Approach to Problem Solving
– Surgical Site Infections (2)
Scope:
Metrics to improve:
Defects: Colorectal Surgical Site Infections (SSIs)
Goal: Reduce colorectal surgical site infections by 50%.
Primary: Observed Rate of Patients with Colorectal SSIs (within 30 days of
the procedure)
Secondary: Observed over Expected (O/E) Ratio for Colorectal SSIs
12
© Copyright, The Joint Commission
All patients undergoing colorectal surgery (emergency and elective)
regardless of who (i.e., which clinical discipline) performs the surgery. NSQIP
CPT codes for colorectal surgery. All types of Surgical Site Infections
(Superficial Incisional, Deep Incisional, and Organ/Space).
Exclude: Trauma and Transplant patients. Patients under 18 years of age.
Process starts: Pre-admission Process ends: 30 days post surgery
Dominique LaRochelle, MHA
Project Manager
Cleveland Clinic Quality & Patient Safety Institute
13
14
Quality and Patient Safety
© Copyright, The Joint Commission
Cleveland Clinic
Developing Effective Teams…
Who is going to solve this important problem?
15
Quality and Patient Safety Institute  8 April 2015  15
Complex Environment
Nurses
Physicians
How to Align?
Unit Secretaries
Coders
Case Managers
Patient Access
Patient
Administration
Operations
16
Quality and Patient Safety Institute  8 April 2015  16
Identifying a Project Team - RACI
R
A
C
I

Quality Improvement

Quality Management
Colorectal Services


Perioperative Services







Inpatient Colorectal
Services

Pharmacy
Infection Control /
Infectious Disease


Environmental
Services
Safety / Clinical Risk /
Accreditation



Sterile Processing

Data

17
Quality and Patient Safety Institute  8 April 2015  17
Project Team
 Who is going to solve this important problem?
Sponsor
Chief Quality Officer
Champion
Surgeon Leader
Process Owner
Colorectal Surgery
Black Belt
Director of Quality Improvement
Core Team
Quality Improvement Project Manager
Quality Management
Peri-operative Services Nurse Managers (Admission & PACU)
Nurse Manager Colorectal Services
OR Nurse Manager Colorectal Services
Wound Care specialist
Infection Prevention
18
Quality and Patient Safety Institute  8 April 2015  18
Project Team
 Subject Matter Experts:
Stakeholder
Represented Area
Quality and Patient
Safety Institute
Quality Improvement
Quality Management
Safety
Accreditation
Colorectal Services
Digestive Disease Institute – Administration & Physician Leadership
Quality Review Officers
Pre-op: Nursing, Education, Staff, Management, Anesthesia, Dietary
Post-op: Nursing, Education, Staff, Management, Wound Care, Dietary
Surgical Operations
Administration / Physician Leadership
PACE, PACU, IMPACT clinics
Nursing, Staff, Anesthesia
Pharmacy
Pharmacists
Environmental Services
OR & Inpatient management
Sterile Processing
Surgical Tech Management / Education
Equipment Vendors
Data
NSQIP
ARKS
Nursing Informatics
Clinical Risk Management
Infection Control / Infectious Disease
Data Resource Management
Medical Records Data / Health Data Services
Business Intelligence (EBI)
19
Quality and Patient Safety Institute  8 April 2015  19
Analysis Strategy
Cause/Effect Analysis
Multi-Vari Analysis
Improvements
Validation
Benchmarking & SMEs
Impact/Effort Analysis
20
Quality and Patient Safety Institute  8 April 2015  20
SIPOC Analysis
 Met with 3 teams of core team members to map perioperative process: Pre-, Intra-, Post- Op
 Expanded upon SIPOC to explore cause & effect
relationships
 Fishbone Diagram
 Cause & Effect scale: Numerical score, 1-5, based on process
variable and its relationship to our output; SSI
– Subjective findings using area experts
– Narrowed the scope to help us focus on a few key processes
– Key processes can then be further explored using objective
data
21
Quality and Patient Safety Institute  8 April 2015  21
SIPOC
22
Cause & Effect Analysis
Technique
Materials / Equipment
Patient hand-off
Communication
Antiseptic Shower/Bath
OR Cleaning Solutions
Patient Health
OR dress code compliance
Wound Care Materials / Equipment
Post-op Education
Hair Removal
Surgeon Scrub Technique (HH)
Wound Care Technique (HH)
Bed Linen Type
Aseptic Practice / Sterile Technique
Equip. Sterilization
Bed Type
Platelet Count
Inpt. Rm Cleaning
Warming Device
Wound Dressing Material
Isolation Patient
Anemia
D/C Instructions
Procedure Type – Minor v. Major
Surgical Equipment
Diet/Nutrition
Freq. Bed Linen Change
Intra / Post-op Pt Temp.
Inpt Rm Cleaning Solutions
BMI
Glucose levels
Pre-op Pt Edu
Wound Dressing Technique
Diagnosis / Disease
OR Cleaning Process
Age
1 Surgeon: Multiple OR’s
Comorbidities
Combo Surgical Case
Ethnicity/Culture
SSI
Geographic Location (Pt.)
Private v. Semi-Private Recovery Rm
Socio-economic Status
Pre-op Medications
Inpt Room Traffic
OR traffic
Post-op Abx
Post-op Recovery Location
Discharge Location
Pre-Op Pain Mgmt
Post-op Glucose
PACU Traffic
Surgery Location (OR)
Central Line
Staff Change(s)
OR Humidity
Post-op Pain Mgmt
Pre-op Abx
OR Temperature
Surgical Fellowship Turnover
Dressing Change
Inpt Unit
Surgical Team Consistency
OR Cleaning Crew
Post-op Pt Diet/Hydration
EVS
Shift Changes During Surgery
Repeat Abx
Abx Selection
Post D/C Follow-up
OR Air Filter Maintenance
Environment
Wound Care Specialist
Post-op Medications
RN Hours/Patient Day
Post-op LOS
Clinical Decision Making
23
Quality and Patient Safety Institute  8 April 2015  23
Cause & Effect Analysis

Met with SIPOC teams (area experts) to review recorded processes
and narrow our focus using a rating scale 1-5 (Subjective findings)
24
Cause & Effect Analysis

Priority processes were identified to help focus the team’s interventions
Processes Identified as Having the Greatest Impact on Risk of SSI
Pre- Op
Diagnosis / Disease  Focus on chronic inflammation
Isolation Patient, Pre-op infectious agent
Glucose Levels
Diet / Nutrition
Antiseptic Shower or Bath
Patient Demographics  BMI specifically
Intra- Op
Surgeon Scrub Technique (HH)
Aseptic Practice / Sterile technique
Equipment Sterilization Technique
Air Filter Maintenance
Post- Op
RN Hours per Patient Day
Wound Care Technique and Materials (Including HH)
OR PACU/ICU, Patient Hand-off Communication
Post-op Glucose Levels
Patient Diet / Nutrition
Post- Op Medications
Wound Care Specialist, CWOCN
25
Quality and Patient Safety Institute  8 April 2015  25
Analysis Strategy
Cause/Effect Analysis
Multi-Vari Analysis
Improvements
Validation
Benchmarking & SMEs
Impact/Effort Analysis
26
Quality and Patient Safety Institute  8 April 2015  26
Validating Progress: OR Audits
 Detail observations (April – May 2011)
 Multidisciplinary team
 Broad scope, low n
 Circulating nurse checklist (May – October 2011)
 Led by circulating nurse
 Narrow scope – bundle focus
 High n – intent to capture all eligible cases
27
Quality and Patient Safety Institute  8 April 2015  27
Challenges Encountered
 Impacting how surgeons practice
 Data are imperfect –
 Sampling
 Incomplete process data are available
 Resources are limited
 Data needed to support improvements
 Improvements need to be made
28
Quality and Patient Safety Institute  8 April 2015  28
Sasha Madison, MPH, CIC.
Manager
Infection Prevention and Control Department
29
30
Infection Prevention & Control
 Role in this Project:
−Subject Matter Expert (SME)
−Core team member
−Prior to this project the role of the Infection
Preventionist was focused on surveillance.
 Defining cases, abstracting data,
calculating rates
 Interventions to decrease SSIs were
often individual – not system based
31
Confidential- Protected by California Evidence Code Section 1157
Infection Prevention & Control
 Role in this Project: (during project)
− Core team member: “ team participant”
 Involved in project in all phases: from Define to
Control
− Subject Matter Expert (SME)
 Defining different data sources with team and
reviewing them, along with the definitions, with
the team
 NSQIP vs NHSN
− Interventions to decrease SSIs were system
based
Confidential- Protected by California Evidence Code Section 1157
32
SHC SSI Project Phases & Elements DMAIC
Milestone
Key Elements
Define
Incidence of Surgical Site Infections in colorectal surgery is high, variable, and represents
opportunity for improvement.
Measure
Reduce colorectal surgical site infections by 50% (Observed and Observed/Expected)
Analyze
(Based on
statistical
analysis of
SHC data)
Statistically Significant Variables
(Potential Risk Factors for SSI)





Wound Disruption (0.003)
OR Duration (0.066)
ASA Class > 2 (0.015)
Open/Laparoscopic Procedure (0.054)
Total Hospital LOS (0.036)
Note: Above variables found to be statistically
significant, however not entirely modifiable.
- No Interventions Made
Potential Identified Variables /Opportunities
 Lowest Patient Intra-Operative Temperature
 Post-Operative Wound Care
 Hand Hygiene
 Dressing Removal at 48hrs
 Post-Operative Bathing
 Surgical Closure
 Glove Change Prior to Closing Fascia
 Separate Colorectal Closure Tray
 Tissue Irrigation
- Irrigation Solution Type
 Note: Actual Interventions in blue & Monitoring in green
Improve
Focus on identified causes, target solutions, patient outcomes
Control
Correlate interventions with SSI outcomes and create sustainability plans for any intervention
that successfully decreased SSIs
33
NHSN Publicly Reported Cases- MIDAS Focus Study
MIDAS Focus Objectives:
• Detailed abstraction of elements with
identified areas of opportunity
• Data will be analyzed for any
potential trends and to serve as a
guide for further interventions
• Surgeon specific SSI rates
• Surgical Quality Council Dashboard
will include SSI outcomes
Confidential- Protected by California Evidence Code Section 1157
34
Next Steps & Opportunities
 MIDAS Focus Study on Publicly Reported Cases
− Infection Control SSI surveillance in July/Aug 2011 identified an
opportunity in colorectal surgery
− Data collection focused on elements which are not captured elsewhere
− Need for individual physician communication of infections identified
 Antibiotic Stewardship
− Instituted February 2012
− Review of current prophylaxis guidelines and empiric therapy
 Based on best practice learning through collaborative,
continue glove changes & separate/clean closing
instruments
Confidential- Protected by California Evidence Code Section 1157
35
Elisa Nguyen, RN, MS, CMSRN.
Patient Care Manager
36

Role of Nursing
Wound Management
Postoperative Phase
37
Confidential- Protected by California Evidence Code Section 1157
Role of Nursing
 Key stakeholder
− In all processes that involves caring for patients
 Nursing involvement from different levels collaborating with the
Core Team
− staff nurses
− Unit Educators
− managers
 Process improvement
− We own majority of the process
− What are gaps in the process that could be improved
 Education and training
− Lead the education and training the frontline nurses
Confidential- Protected by California Evidence Code Section 1157
38
MD/RN Collaboration
 Existing Policy and Procedure (P&P)
− No existing one for post-op wound care
management
− Utilized another service’s P&P as a model to
create one for colorectal
 Shared governance approval
− Drafted P&P went to one of the physician lead for
review
− Hospital nursing council for final review and
approval
39
Confidential- Protected by California Evidence Code Section 1157
Post-Operative Wound Management &
DMAIC
Surgical Brochure
Utilizing Surgical
Brochure to
Reinforce critical
need of Post
Operative Wound
Management
Protocol
Confidential- Protected by California Evidence Code Section 1157
40
Tracking the Process
Nursing Action Focus: Conducted to better understand hand hygiene at each
phase of post-op care and to assure that we keep the incisional wound and drain
insertion sites free from contamination in the early post-operative period
 Unit level staff identified process of
implementation
− Unit Clerk – added the audit tool to
admission packet, color coded the
patient’s name of locator board
− Primary Nurse – completed the audit
− Resource Nurse – double checked that
audit was completed
 Data collector
− Quality manager in charge of data
processing
Confidential- Protected by California Evidence Code Section 1157
41
41
What is next?
42
© Copyright, The Joint Commission
How can you participate in this effort?
CTH Operating Model
Determine Topic
Create Solutions, Pilot Test, Build
Spread
Solve with Participating
Organizations
Pilot Test
Integrate
Solutions w/ TST
Launch TST
   18 to 24 months   
43
© Copyright, The Joint Commission
Project
Selection
Introduction to CTH-Spread
– Web-based tool free to Joint Commission
accredited organizations
– No knowledge of RPI methodology needed
– Data analysis conducted by the tool, not the user
– Tool walks user through process of:
– Measuring current state
– Determining root causes
– Selecting targeted solutions
– Control of process after implementation
44
© Copyright, The Joint Commission
Improvement spread through Targeted
Solutions Tool™
Assisting the Center in its aim to
transform health care into a highreliability industry by solving health
care’s most critical safety and quality
problems
Access to the Center solutions prior to
national release
Access to the tools developed and
used by the participating hospitals in
the Surgical Site Infections Project
45
© Copyright, The Joint Commission
Benefits of becoming a pilot site
Pilot participant expectations
RealTime
Analysis
Measure
performance
Implement
targeted
solutions
Webex conference calls occur approximately every 2
weeks throughout pilot
46
© Copyright, The Joint Commission
Create
team
Validate
improve
ments
Feel Free to Contact Us
47
© Copyright, The Joint Commission
 Any information related to the Joint Commission
Center for Transforming Healthcare, the SSI
Collaborative Project and Pilot Participation,
– Please contact Siew Lee Grand-Clément at
SGrand-Clement@jointcommission.org
– Website:
www.centerfortransforminghealthcare.org
48
© Copyright, The Joint Commission
QUESTIONS OR COMMENTS?