SUSP: Improving Surgical Care through TRIP and CUSP Denise Flook, RN, MPH, CIC HAI Lead Vice President, Infection Prevention/Staff Engagement

SUSP: Improving Surgical Care through TRIP and CUSP

Denise Flook, RN, MPH, CIC

HAI Lead

Vice President,

Infection Prevention/Staff Engagement

Learn. Act. Improve. Spread. Keep the Drum Beat Going.

Learning Objectives

1. Provide an overview of the Georgia SUSP Program

2. Outline requirements and expectations

3. Delineate the process to join the collaborative

4. Describe next steps


Framing Our Meeting

• Putting Patients First: Preventing All Cause Harm• Focus on the care of the surgical patient and the

culture of the perioperative area• Take what we have learned in the CUSP work

and move it into the perioperative services area


The SUSP Project

• AHRQ funded project to measurably improve clinical outcomes, teamwork culture, and patient safety in surgery.

• Designed to build on the success of previous programs (CUSP/CLABSI)

• Applies new methods and tools to effectively assist teams with quality improvement in the complex surgical environment.


National Partnerships

• Johns Hopkins Armstrong Institute• American College of Surgeons• University of Pennsylvania • World Health Organization Patient Safety

Programme• In addition, the National Project Team includes

TeamSTEPPS program faculty


Our Goals

• Eliminate preventable harm in surgical patients

• To achieve significant reductions in surgical

site infection and surgical complication rates• To achieve significant improvements in

safety culture


Key Interventions

• Adapt WHO Safe Surgery Checklist• Use tools to improve adherence to evidence based

practices• Adapt and use CUSP and TeamSTEPPS tools • Implement emerging selective interventions based

on hospital resources and culture• Tap into the wisdom of frontline staff • Conduct audits to identify defects in care processes• Use what you have learned to improve SSI and

iother surgical complications


Model for Improvement


9

Implementation Framework


Why Join SUSP Project?

• To improve safety for surgical patients• Opportunity to be part of a national effort with shared learning; • Participate at the forefront of helping to learn how this model

works at the local level;• Improve patient outcomes through cutting edge tools & resources; • Teams develop a heightened sense of purpose by working together

to make things better, reinforcing the value in their work;• Become a member of a surgical learning community and build

relationships that will last longer than the project;• Provision of comparative feedback reports to track hospital

progress;• Opportunity for 10 teams (voluntary) to participate in on-site

interviews and observations by an experienced team to discern barriers and facilitators to project implementation.

• Extra credit points given in Georgia HEN Recognition Program


Team Members

• Project Team Leader: Team primary contact• Physician Champion (medical director or physician who

provides care in the perioperative setting)

• Culture survey (HSOPS) coordinator – make sure that the AHRQ Hospital Survey on Patient

Safety Culture is completed at specified times, administrator

• Hospital Executive or Senior Management Champion • Infection Preventionist/Epidemiologist• Bedside Staff members• Others as identified


Team Focus

• a. One outcome measure: SSI rate; • b. One process measure: use of checklist

like methods to improve surgery safety (briefings/debriefings);

• c. Improving safety and teamwork culture


Hospital Requirements

• Assemble a multidisciplinary team including frontline staff in the Preop, OR, and Postop

areas;

• Participate in 7 weekly on-boarding calls;

• Participate on monthly content calls;

• Participate on monthly coaching calls;

• Participate in annual face-to-face meetings;

• Regularly meet as a team to implement interventions and monitor performance.


On Boarding Calls

Call Date Topic

1 February 5February 7

SUSP Overview


Building Your SUSP Team, Part 1


Science of Safety


CUSP

5 March 5March 7

SSI Prevention

6 March 12March 14

Building Your SUSP Team, Part 2

7March 19March 21

Assessing Patient Safety Culture

8March 26March 28

SUSP Data Platform

9April 2April 4

Administering the Hospital Survey on Patient Safety (HSOPS) for the SUSP project (for HSOPS coordinators)

Calls are offered twice a week: Tuesdays 7:00 to 8:00 am and Thursdays 3:00 to 4:00 pm


Time and Staff Commitments

• SUSP teams ideally dedicate 2-4 hr/week for a nurse, surgeon, anesthesia, team leader, and infection preventionist to lead these efforts;

• Participate in seven (7) weekly on-boarding calls;• Have at least one team member participate in monthlycontent and

coaching teleconferences for the remaining 22 months;• Attend annual day long learning sessions (video, face to face, or

similar interactive format); • Comply with data collection and submission requirements;• Learn and implement the collaborative improvement tools; • Hold regular safety meetings to review SSI outcome and teamwork

and communication data; and• Use monthly SSI outcome data, and annual HSOPS data to improve

performance.


Data Requirements

• Monthly surgical site infection data (numerator and denominator) each month

• Quarterly project implementation data (structured interview and brief survey);

• Annual teamwork/culture data using the AHRQ Hospital

• Where data are already collected/available (for example through ACS NSQIP or NHSN), will work with JH to import already available data if you desire.


Measures and Dates

MEASURE DATA ENTRY LOCATION DATES

SSI Rates (Outcome)

Superficial surgical site infection (includes primary and secondary site)

Deep surgical site infection

Organ space surgical site infection

Population at risk for surgical site infection

AI SUSP Platform

or via NSQIP, HEN, State Hospital Association through NHSN

Baseline: 3 Months

Implementation: Monthly

Quarterly Interview Assessment of Implementation Fidelity

Evaluate how the unit-team is implementing CUSP and SSI activities

Telephone Interview with interviewer from SUSP National

Leadership Quarterly

Hospital Survey on Patient Safety (HSOPS)

* Assess cultural (CUSP) components AI SUSP Platform

Two Times:

Start of Project

12+ Months


Next Steps

1. Review the materials with Senior Executive

2. Make commitment to participation in the project

3. Have the CEO (or designated Senior Executive) sign the Commitment Form and send to Denise Flook at [email protected] or fax 770-249-4591

4. Develop a basic clinical team and send in Clinical Team Participant Agreement.

5. Forms should be sent ASAP or no later than Feb 8 if possible.

6. Listen to onboarding calls

mailto:[email protected]


Questions?


CONTACT INFORMATION

Denise Flook

[email protected].

770-249-4518

mailto:[email protected]

Documents

SUSP: Improving Surgical Care through TRIP and CUSP Denise Flook, RN, MPH, CIC HAI Lead Vice President, Infection Prevention/Staff Engagement