Surgical Infection Prevention Collaborative Northwest · 2019-11-28 · Surgical Infection Prevention Collaborative Northwest. will involve hospital teams from Idaho, Oregon, and

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.


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.

Getting Started

4 SIP Collaborative Northwest Handbook

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


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.


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.

Pre-Work Activities


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,

Pre-work Activities


� 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

Pre-Work Activities


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.

Pre-work Activities


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.

http://www.ompro.org/sip-nw

Pre-Work Activities


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.

Pre-work Activities


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):

Pre-Work Activities


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.

Pre-work Activities


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.

Pre-Work Activities

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


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

Pre-Work Activities Worksheet


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:

Pre-work Activities Worksheet


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.

Pre-Work Activities Worksheet


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:


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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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

Charter


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

Charter


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;

Charter


• 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.

Charter


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. 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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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

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Measurement Strategy


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.


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


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


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


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


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


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


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

[email protected]

Lynn Masciarotte, RN, BSN, CPHQ

OMPRO

2020 SW Fourth Avenue, Suite 520

Portland, OR 97201-4960

503.279.0100

[email protected]

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

[email protected]

Kathryn Bunt

Qualis Health


PO Box 33400

Seattle, WA 98133-0400

206.364.9700, ext. 2259

[email protected]

Idaho Improvement Lead Oregon Improvement LeadJane Burgman, RN

Qualis Health

720 Park Blvd., Suite 120

Boise, ID 83712-7756

208.389.5035

[email protected]

Donna Thatcher, RN, CPHQ

OMPRO

2020 SW Fourth Avenue, Suite 520

Portland, OR 97201-4960

503.279.0100

[email protected]

Washington Improvement LeadSusan Hausmann, MS

Qualis Health


PO Box 33400

Seattle, WA 98133–0400

206.364.9700, ext. 2890

[email protected]

mailto:[email protected]

mailto:[email protected]

Documents

Surgical Infection Prevention Collaborative Northwest · 2019-11-28 · Surgical Infection Prevention Collaborative Northwest. will involve hospital teams from Idaho, Oregon, and