Implementing your SSI Bundle 1 Armstrong Institute for Patient Safety and Quality Presented by: Sean...

Implementing your SSI Bundle

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Armstrong Institute for Patient Safety and QualityPresented by: Sean Berenholtz, M.D.

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Some quick administrative announcements

• You need to dial into the conference line to hear audio:

– Dial in Calls: 1-800-311-9401

– Passcode: 120816

• Please contact your Coordinating Entity for a copy of these slides if you have not already received them.

We will record this webinar and provide an MP3 audio file on the Armstrong Institute SUSP website:

https://armstrongresearch.hopkinsmedicine.org/susp.aspx

Draft-Pending AHRQ Review

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Polling Question

What is your role in your clinical area?SurgeonQuality Improvement practitionerInfection preventionistOR nurseOR technicianAnesthesiologistOR managerEducatorOther


Learning Objectives

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• Create an implementation plan for your SSI prevention bundle using a proven implementation framework.

• Use the Barrier Identification and Mitigation (BIM) Tool to address local barriers to implementation of your SSI prevention bundle.


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Polling Questions

• Did you have an existing technical bundle developed prior to joining the SUSP project?

Yes

No

• Will you modify your existing bundle for this project?

Yes

No


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SSI Bundle Characteristics1,2,3

• A collection of evidence-based practices

• Tailored to your environment

• 5 to 7 elements

• Dynamic and evolving

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No single SSI prevention bundle?

• Dive deeper into SCIP measures to identify local defects

• Emerging evidence

• Capitalize on frontline wisdom

– CUSP / Staff Safety Assessment

Abx redosing & weight

based dosing

Maintenance of

normogylcemia

Mechanical bowel

preparation with oral abx

Standardization of skin

preparation

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Three Ways to Surface Defects: Review

• PSSA - Staff Safety Assessment

• SSI Investigation Tool

• Auditing tools

– Glucose control audit tool

– Normothermia audit tool

– Skin prep audit tool

– Antibiotic audit tool

The SSI Investigation toolkit and audit tools are on the SUSP website:

https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx.


https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx

https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx

TRANSLATING EVIDENCE INTO BEDSIDE PRACTICE

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Translating Evidence into Practice4

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• Summarize the evidence

– For your SUSP project, focus on your SSI bundle

• Identify local barriers to implementation

• Measure performance

• Ensure all patient receive the intervention


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– Observe staff performing the interventions

– “Walk the process” to identify defects

– Enlist all stakeholders to share concerns




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• Knowledge– Awareness or familiarity (n=77)

• Attitudes– Agreement (n=33)– Self-efficacy (n=19)– Outcome expectancy (n=8)– Inertia of previous practice (n=14)

• Behavior (Ability)– External barriers (n=34)

Why Don’t Clinicians Follow the Guidelines?5


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• Ideal for use as part of a broader safety improvement project, such as SUSP.

• Designed to identify and prioritize barriers to guideline compliance in your clinical area.

• Provides a framework for developing an action plan.

Use BIM to identify local barriers of implementation

Barrier Identification & Mitigation (BIM)

Use the BIM Tools as a guide! Download from the SUSP website:

https://armstrongresearch.hopkinsmedicine.og/susp/ssi/resources.aspx.


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Steps of BIM• Assemble the BIM Team

• Identify the Barriers

• Summarize Barrier Information

• Prioritize Barriers Based on Impact and Feasibility

• Develop a BIM Action Plan for each Targeted Barrier

Barrier Identification & Mitigation (BIM)

Use the BIM Tools as a guide! Download from the SUSP website:

https://armstrongresearch.hopkinsmedicine.og/susp/ssi/resources.aspx.

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• Subset of the SUSP team

• Front line staff

• Extended faculty members

• Other faculty / staff experts

• New partnerships with other clinicians

Assemble the BIM Team

Activity: Identify roles for your ideal BIM Team. How can the BIM process empower and motivate staff?

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The BIM Tool walks through a series of questions focused on three categories:

Identify the Barriers

Clinician

• Knowledge• Attitudes• Behavior• Compliance

Environment

• Task• Tools &

Technology• Administrative

support• Performance

monitoring / feedback

• Perioperative culture

Guideline

• Applicability• Ease of

Compliance


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Factors Barriers Potential Actions

C L I N I C I A N

Knowledge of the guidelineDoes the clinician know how to comply with the guideline?

Attitude regarding the guidelineDoes the clinician believe that following the guideline will reduce infection rates?

Current practice habitsWhat does the clinician currently do (or not do)?

Perceived guideline adherenceHow often does the clinician do everything right?

Identify the Barriers: BIM ToolGuideline: Data collection mode (Check one):

Observe the Process Discuss the Process Walk the Process

Investigator: Shift:


Factors Barriers Potential Actions

W O R K E N V I R O N M E N T

TaskWho is responsible for following the guideline?

Tools & technologiesWhat supplies & equipment are available/used?

Administrative supportHow does current administrative support affect adherence?

Performance monitoring/feedbackHow do clinicians know they are following the guideline?

Perioperative cultureHow does the perioperative culture affect adherence?

Identify the Barriers: BIM Tool

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Barrier Likelihood Score Severity Score Barrier Priority

Score

Summarize & Prioritize the Barriers

Team scores each barrier from 1

(unlikely to occur) to 5 (very likely to occur).

The Severity Score represents the

probability that the barrier, if encountered, would lead to guideline

non-adherence.

Barrier Priority Score

Likelihood

Score

Severity

ScoreThe higher the Barrier Priority Score for a barrier, the more critical it is to eliminate or decrease the effects of that barrier.


Selected Actions Performance Measures

Who’s in charge of

these efforts?Follow-up date

Develop a BIM Action Plan

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– Select process or outcome measures

– Audit and SSI investigation tools



Measure Performance: Auditing Resources

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Surgical Care Audit Tools

• Glucose Control• Normothermia• Skin Preparation• SSI Investigation • Antibiotic

Keep in Mind: Tools should be adapted to your local environment. Be empowered to customize the tools to meet the needs of your area.

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https://armstrongresearch. hopkinsmedicine.org/ susp.aspx

Measure Performance: Portal Resources



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Measure Performance: Portal Resources


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Identifying defects for patients that develop a

SSI is feasible. It engages staff members with

a common goal, puts a face to the numbers,

and most importantly, is EASY to do.

-- SUSP Team Member

“

”

Real World Applications


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• Ensure all patients receive the intervention

– Engage, educate, execute, evaluate

– Educate staff on the science of improving patient safety


LEADING CHANGE WITH THE 4 E’S

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Implementation: Starting with 4 E’s

Senior executives

Team leaders

Frontline staff

EngageEducate

ExecuteEvaluate

Win the hearts & minds of your team(s)

Teach your team(s) about your intervention

Implement your plan with purposeful team participation

Determine how well your effort has improved care processes & outcomes

Strategies will depend on YOUR Stakeholders


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To help with 4E’s, choose partners:

Key Partnerships

Surgeons

Anesthesiologists

CRNAs

Circulating nurses

Scrub nurses / OR techs

Perioperative nurses

Executive partner

Nurse leaders

Physician assistants

Nurse educators

Anesthesia assistants

Infection preventionists

OR directors

Patient safety officers

Chief quality officers

Ancillary staff


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I have all these powers, but no one listens to me!

It takes a villagean engaged

Engage

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• Share about a patient who was infected

• Share stories about when staff ensured patients received the evidence

• Post baseline rates of infections and number of patients with an SSI

• Remind staff that most SSI’s are likely preventable


Fostering Engagement

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Intrinsic motivation

Internal, psychological rewards that derive from the work itself

Extrinsic motivation

External rewards or incentives attached to the work

Activity: List several examples of both intrinsic and extrinsic motivators.


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Celebrating Our Heroes


Educate

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Important yet challenging task

Most leaders overestimate what their staff knows about the SUSP project, so keep sharing

Find creative and consistent messaging to communicate to your teamInservices

•Conduct training on SSI prevention

Forums

•Jointly educate physicians and nurses

Orientation

•Add SSI prevention to unit orientation

Evidence

•Provide staff with evidence-fact sheets, articles and slides

Boards

•Visually display SSI stories, goals, facts & teamActivity: Any other examples of ways to educate staff members?

Execute: The Principles of Safe Design6

• Standardize what is done and when it is done

– Reduce complexity

• Create independent checks for key processes

– How often do we do what we should?

• Learn from defects and share feedback

– How often do we learn from defects?

To learn more about Science of Safety, watch this video: https://armstrongresearch.hopkinsmedicine.org/susp.aspx#

Principles apply to BOTH technical tasks and teamwork.




Briefings and Debriefings

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• Reductions in communication breakdowns and OR delays7

• Reductions in procedure and miscommunication-related disruptions and nursing time spent in core8

• Improved communication and teamwork, feasible given current workload9

• Reductions in rate of any complications, SSI and mortality10

It is essential to adapt tools to the local

environment.

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• No follow-up on comments

• Too long

• Same form used in all OR’s (neurosurgery, ortho, general surgery)

Briefings & Debriefings


“Real time” Identification of Defects11

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• Customize form based on your specific needs

• Add your components to the bundle

• Address defects with infrastructure & communication

• Log defectsDraft-Pending AHRQ Review

Debriefing Defect Logbook

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Example of Defects Addressed: Instruments

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ProblemConflict with colorectal set

Solution• Increased fleet from 2 to 4• Reorganized set contents so it

is only pulled for cases when really needed

Impact

Instruments available when needed Draft-Pending AHRQ Review

WIFM: What’s In It For Me?

• Briefings and debriefings are an effective strategy to standardize care and create independent checks.

• It’s important to move staff from compliant to engaged.

• Briefing and debriefings form needs to be customized to address your targeted defects.

• Close the loop to solve defects.

Activity: Any other ideas?

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Evaluate

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• An equally important and challenging task• Its essential to report progress to your team

– Download SSI reports from the SUSP/SSI Data Portal to track your rates and detect trends.

– Post your progress in the unit and discuss during staff meetings.

To get a tutorial on how to download SSI reports from the SUSP portal, check out the manual on our website:

https://armstrongresearch.hopkinsmedicine.org/susp/resources.aspx


https://armstrongresearch.hopkinsmedicine.org/susp/resources.aspx

Colorectal SSI Rate by Quarter (NSQIP)

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Baseline Year 1 Year 2 Year 3SSI Rate: 27% SSI: 17% SSI Rate: 20% SSI Rate: 11%

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Summary

• No single SSI prevention bundle

• Surface and address local defects

• Briefings and debriefings to standardize and create redundancy

• 4 E’s model to guide change

EngageEducate

Execute

Evaluate


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Recap of Learning Objectives

• Create an implementation plan for your SSI prevention bundle using a proven implementation framework.

• Use the Barrier Identification and Mitigation (BIM) Tool to address local barriers to implementation of your SSI prevention bundle.


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Discussion Questions

How will you develop and implement your SSI bundle?

How will you engage staff and clinicians?

What will your SSI bundle include?

Activity: What are your top take-aways from presentation?


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References

1. Crolla RM, van der Laan L, Veen EJ, Hendriks Y, van Schendel C, Kluytmans J. Reduction of surgical site infections after implementation of a bundle of care. PloS one 2012;7:e44599.

2. Wick EC, Hobson DB, Bennett JL, Demski R, Maragakis L, Gearhart SL, Efon J, Berenholtz SM, Makary MA. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg 2011;215:193-200.

3. Hedrick TL, Heckman JA, Smith RL, Sawyer RG, Friel CM, Foley EF. Efficacy of protocol implementation on incidence of wound infection in colorectal operations. J Am Coll Surg 2007;205:432-8.

4. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large-scale knowledge translation. BMJ 2008;337:963-965.

5. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA;282(15):1458-1465


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6. Pronovost PJ, Goeschel CA, Marsteller JA, Sexton JB, Pham JC, Berenholtz SM. Framework for patient safety research and improvement. Circulation 2009;119:330-337.

7. Nundy S, Mukherjee A, Sexton JB, Pronovost PJ, Knight A, Rowen LC, Duncan M, Syin D, Makary MA. Impact of preoperative briefings on operating room delays: a preliminary report. Arch Surg. 2008;143(11): 1068-1072.

8. Henrickson SE, Wadhera RK, Elbardissi AW, Wiegmann DA, Sundt TM. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009;208:1115-1123.

9. Berenholtz SM. Et al. Implementing standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Saf. 2009;35(8):391-397.

10. Haynes AB. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-9.

11. Bandari J. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical cneter. Jt Comm J Qual Saf 2012;38(4):154-160

References


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