Joint Commission Center for Transforming Healthcare (CTH)

1. Joint Commission Center for Transforming Healthcare (CTH) Partnering for Success in Reducing Surgical Site Infections Cynosure Health Summit 21st May 2012

2. Siew Lee Grand-Clément RN, MSN, CPHQ Center Project Leader: Surgical Site Infections CollaborativeJoint Commission Center for Transforming Healthcare (CTH) 2

3. Objectives • To explain the collaborative working model of the Joint Commission Center for Transforming Healthcare. • To describe the problem solving methodology used in reducing Surgical Site Infections. • To identify the key stakeholders involved and describe the process of forming an effective multi-disciplinary team. • To demonstrate the use of infection control and prevention practices in driving improvements. • To illustrate the roles of nursing in process improvement initiative. 3

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5. Introduction to CTH-Vision One Vision All people always experience the safest, highest quality, best-value health care across all settings. 5

6. Why the CTH was Created • Our Mission - Transform health care into a high reliability industry and to ensure patients receive the safest, highest quality care they expect and deserve. • Presents a new approach to address critical safety and quality problems sought by The Joint Commission, health care organizations, patients and their families, physicians and other clinicians, and other public and private stakeholders

7. What’s Different About the Center? • Unique approach to improvement: • Center for Transforming Healthcare (CTH) collaborating with HCOs and hospital leaders where lean, six sigma are already working • Powerful process improvement tools (RPI) • Underlying causes, targeted solutions • Integrated change management for acceptance and accountability • Engaging industry coupled with reach of TJC • Leadership Advisory Council Members & Sponsors • Ability to spread solutions to 19,000+ accredited health care organizations in US 7

8. Introduction to CTH-Targeting Root Causes 8

9. Introduction to CTH-Projects • Project 1 – Hand Hygiene Compliance • Project 2 – Wrong Site Surgery • Project 3 – Hand Off Communication • Project 4 – Surgical Site Infections • With American College of Surgeons • Project 5 – Preventing Avoidable Heart Failure Hospitalizations • With American College of Physicians • Project 6 – Safety Culture • Project 7 – Preventing Falls with Injury • Project 8 – Reducing Sepsis Mortality • Project 9 – Medication Safety 9

10. Collaborate with American College of Surgeons & NSQIP measurement system leveraged. Seven participating hospitals: Mayo Clinic, MN Cleveland Clinic, OH Stanford Hospital & Clinics, CA OSF Saint Francis, IL Northwestern Memorial Hospital, IL North Shore LIJ, NY Cedars-Sinai Medical Center, CA Project #4: Surgical Site Infections 10

11. Systematic Approach to Problem Solving – Surgical Site Infections (1) • The Center worked with the American College of Surgeons to determine the scope of the SSI project, since there is a wide range of surgeries and procedures that can develop SSIs – each with its own unique set of complications and challenges. • To help narrow the scope of the project, the following criteria were used to identify a specific procedure that: • Is common across different types of hospitals • Has significant complications with an adverse clinical impact • Hospitals have significant opportunities to improve performance • Has high variability in performance across hospitals

12. Systematic Approach to Problem Solving – Surgical Site Infections (2) Scope: All patients undergoing colorectal surgery (emergency and elective) regardless of who (i.e., which clinical discipline) performs the surgery. NSQIP CPT codes for colorectal surgery. All types of Surgical Site Infections (Superficial Incisional, Deep Incisional, and Organ/Space). Exclude: Trauma and Transplant patients. Patients under 18 years of age. Process starts: Pre-admission Process ends: 30 days post surgery Metrics to improve: Defects: Colorectal Surgical Site Infections (SSIs) Goal: Reduce colorectal surgical site infections by 50%. Primary: Observed Rate of Patients with Colorectal SSIs (within 30 days of the procedure) Secondary: Observed over Expected (O/E) Ratio for Colorectal SSIs

13. Dominique LaRochelle, MHA Project Manager Cleveland Clinic Quality & Patient Safety Institute 13

14. Quality and Patient Safety Institute  1 January 2020  14 Cleveland Clinic 14

15. Developing Effective Teams… Who is going to solve this important problem? 15 Quality and Patient Safety Institute  1 January 2020  15

16. Patient Complex Environment Nurses Physicians How to Align? Unit Secretaries Coders Case Managers Patient Access Operations Administration 16 Quality and Patient Safety Institute  1 January 2020  16

17. Identifying a Project Team - RACI 17 Quality and Patient Safety Institute  1 January 2020  17

18. Project Team • Who is going to solve this important problem? 18 Quality and Patient Safety Institute  1 January 2020  18

19. Project Team • Subject Matter Experts: 19 Quality and Patient Safety Institute  1 January 2020  19

20. Validation Analysis Strategy Cause/Effect Analysis Multi-Vari Analysis Improvements Benchmarking & SMEs Impact/Effort Analysis 20 Quality and Patient Safety Institute  1 January 2020  20

21. SIPOC Analysis • Met with 3 teams of core team members to map peri-operative process: Pre-, Intra-, Post- Op • Expanded upon SIPOC to explore cause & effect relationships • Fishbone Diagram • Cause & Effect scale: Numerical score, 1-5, based on process variable and its relationship to our output; SSI • Subjective findings using area experts • Narrowed the scope to help us focus on a few key processes • Key processes can then be further explored using objective data 21 Quality and Patient Safety Institute  1 January 2020  21

22. SIPOC 22

23. Cause & Effect Analysis 23 Quality and Patient Safety Institute  1 January 2020  23

24. Cause & Effect Analysis • Met with SIPOC teams (area experts) to review recorded processes and narrow our focus using a rating scale 1-5 (Subjective findings) 24

25. Cause & Effect Analysis • Priority processes were identified to help focus the team’s interventions 25 Quality and Patient Safety Institute  1 January 2020  25

26. Validation Analysis Strategy Cause/Effect Analysis Multi-Vari Analysis Improvements Benchmarking & SMEs Impact/Effort Analysis 26 Quality and Patient Safety Institute  1 January 2020  26

27. Validating Progress: OR Audits • Detail observations (April – May 2011) • Multidisciplinary team • Broad scope, low n • Circulating nurse checklist (May – October 2011) • Led by circulating nurse • Narrow scope – bundle focus • High n – intent to capture all eligible cases 27 Quality and Patient Safety Institute  1 January 2020  27

28. Challenges Encountered • Impacting how surgeons practice • Data are imperfect – • Sampling • Incomplete process data are available • Resources are limited • Data needed to support improvements • Improvements need to be made 28 Quality and Patient Safety Institute  1 January 2020  28

29. Sasha Madison, MPH, CIC. ManagerInfection Prevention and Control Department

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31. Infection Prevention & Control • Role in this Project: • Subject Matter Expert (SME) • Core team member • Prior to this project the role of the Infection Preventionist was focused on surveillance. • Defining cases, abstracting data, calculating rates • Interventions to decrease SSIs were often individual – not system based 31

32. Infection Prevention & Control • Role in this Project: (during project) • Core team member: “ team participant” • Involved in project in all phases: from Define to Control • Subject Matter Expert (SME) • Defining different data sources with team and reviewing them, along with the definitions, with the team • NSQIP vs NHSN • Interventions to decrease SSIs were system based

33. DMAIC SHC SSI Project Phases & Elements Note: Above variables found to be statistically significant, however not entirely modifiable. - No Interventions Made

34. NHSN Publicly Reported Cases- MIDAS Focus Study • MIDAS Focus Objectives: • Detailed abstraction of elements with identified areas of opportunity • Data will be analyzed for any potential trends and to serve as a guide for further interventions • Surgeon specific SSI rates • Surgical Quality Council Dashboard will include SSI outcomes

35. Next Steps & Opportunities • MIDAS Focus Study on Publicly Reported Cases • Infection Control SSI surveillance in July/Aug 2011 identified an opportunity in colorectal surgery • Data collection focused on elements which are not captured elsewhere • Need for individual physician communication of infections identified • Antibiotic Stewardship • Instituted February 2012 • Review of current prophylaxis guidelines and empiric therapy • Based on best practice learning through collaborative, continue glove changes & separate/clean closing instruments

36. Elisa Nguyen, RN, MS, CMSRN. Patient Care Manager

37. Role of Nursing Wound Management Postoperative Phase

38. Role of Nursing • Key stakeholder • In all processes that involves caring for patients • Nursing involvement from different levels collaborating with the Core Team • staff nurses • Unit Educators • managers • Process improvement • We own majority of the process • What are gaps in the process that could be improved • Education and training • Lead the education and training the frontline nurses

39. MD/RN Collaboration • Existing Policy and Procedure (P&P) • No existing one for post-op wound care management • Utilized another service’s P&P as a model to create one for colorectal • Shared governance approval • Drafted P&P went to one of the physician lead for review • Hospital nursing council for final review and approval

40. Post-Operative Wound Management & Surgical Brochure DMAIC Utilizing Surgical Brochure to Reinforce critical need of Post Operative Wound Management Protocol

41. Tracking the Process Nursing Action Focus: Conducted to better understand hand hygiene at each phase of post-op care and to assure that we keep the incisional wound and drain insertion sites free from contamination in the early post-operative period • Unit level staff identified process of implementation • Unit Clerk – added the audit tool to admission packet, color coded the patient’s name of locator board • Primary Nurse – completed the audit • Resource Nurse – double checked that audit was completed • Data collector • Quality manager in charge of data processing 41

42. What is next? How can you participate in this effort? 42

43. CTH Operating Model Spread Project Selection Create Solutions, Pilot Test, Build Solve with Participating Organizations Determine Topic Pilot Test Integrate Solutions w/ TST Launch TST    18 to 24 months    43

44. Introduction to CTH-Spread • Improvement spread through Targeted Solutions Tool™ • Web-based tool free to Joint Commission accredited organizations • No knowledge of RPI methodology needed • Data analysis conducted by the tool, not the user • Tool walks user through process of: • Measuring current state • Determining root causes • Selecting targeted solutions • Control of process after implementation 44

45. Benefits of becoming a pilot site • Assisting the Center in its aim to transform health care into a high-reliability industry by solving health care’s most critical safety and quality problems • Access to the Center solutions prior to national release • Access to the tools developed and used by the participating hospitals in the Surgical Site Infections Project 45

46. Pilot participant expectations Webex conference calls occur approximately every 2 weeks throughout pilot 46

47. Feel Free to Contact Us • Any information related to the Joint Commission Center for Transforming Healthcare, the SSI Collaborative Project and Pilot Participation, • Please contact Siew Lee Grand-Clément at SGrand-Clement@jointcommission.org • Website: www.centerfortransforminghealthcare.org 47

48. Questions or Comments? 48