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Implementing your SSI Bundle

Implementing your SSI Bundle. Armstrong Institute for Patient Safety and Quality Presented by: Sean Berenholtz , M.D. . Some quick administrative announcements. You need to dial into the conference line to hear audio: Dial in Calls: 1 -800-311-9401 Passcode : 83762

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Implementing your SSI Bundle

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

  2. Some quick administrative announcements • You need to dial into the conference line to hear audio: • Dial in Calls: 1-800-311-9401 • Passcode: 83762 • 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

  3. Polling Question • What is your role in your clinical area? • Surgeon • Quality Improvement practitioner • Infection preventionist • OR nurse • OR technician • Anesthesiologist • OR manager

  4. Polling Question What affinity groups would your hospital be interested in joining? (Select all that apply) • Enhanced Recovery Protocol • Bowel prep/oral antibiotics, glucose control  • OR traffic, environmental, sterile technique (environmental issues) • Skin prep, abx, normothermia (SCIP measures)

  5. 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.

  6. Polling Questions • Did you have an existing technical bundle developed prior to joining the SUSP call? • Yes • No • Will you modify your existing bundle for this project? • Yes • No

  7. SSI Bundle Characteristics1,2,3 • A collection of evidence-based practices • Tailored to your environment • 5 to 7 elements • Dynamic and evolving

  8. No single SSI prevention bundle? • Dive deeper into SCIP measures to identify local defects • Emerging evidence • Capitalize on frontline wisdom • CUSP / Staff Safety Assessment Abxredosing & weight based dosing Maintenance of normogylcemia Mechanical bowel preparation with oral abx Standardization of skin preparation

  9. 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.

  10. Translating Evidence into Bedside Practice

  11. TranslatingEvidence into Practice4 • 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

  12. TranslatingEvidence into Practice4 • Summarize the evidence • Identify local barriers to implementation • Observe staff performing the interventions • “Walk the process” to identify defects • Enlist all stakeholders to share concerns • Measure performance • Ensure all patient receive the intervention

  13. Why Don’t Clinicians Follow the Guidelines?5 • 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)

  14. Barrier Identification & Mitigation (BIM) Use BIM to identify local barriers of implementation • 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 the BIM Tools as a guide! Download from the SUSP website: https://armstrongresearch.hopkinsmedicine.og/susp/ssi/resources.aspx.

  15. Barrier Identification & Mitigation (BIM) 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 Use the BIM Tools as a guide! Download from the SUSP website: https://armstrongresearch.hopkinsmedicine.og/susp/ssi/resources.aspx.

  16. Assemble the BIM Team • Subset of the SUSP team • Front line staff • Extended faculty members • Other faculty / staff experts • New partnerships with other clinicians Activity: Identify roles for your ideal BIM Team. How can the BIM process empower and motivate staff?

  17. Identify the Barriers The BIM Tool walks through a series of questions focused on three categories:

  18. Identifythe Barriers: BIM Tool

  19. Identifythe Barriers: BIM Tool

  20. Summarize & Prioritize the Barriers The Severity Score represents the probability that the barrier, if encountered, would lead to guideline non-adherence. Team scores each barrier from 1 (unlikely to occur) to 5 (very likely to occur). Likelihood Score Severity Score Barrier Priority Score The higher the Barrier Priority Score for a barrier, the more critical it is to eliminate or decrease the effects of that barrier.

  21. Developa BIM Action Plan

  22. Translating Evidence into Practice4 • Summarize the evidence • Identify local barriers to implementation • Measure performance • Select process or outcome measures • Audit and SSI investigation tools • Ensure all patient receive the intervention

  23. Measure Performance: Auditing Resources Keep in Mind: Tools should be adapted to your local environment. Be empowered to customize the tools to meet the needs of your area. Surgical Care Audit Tools Glucose Control Normothermia Skin Preparation SSI Investigation Antibiotic

  24. Measure Performance: Portal Resources https://armstrongresearch. hopkinsmedicine.org/ susp.aspx

  25. Measure Performance: Portal Resources

  26. Real World Applications “ 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 ”

  27. Translating Evidence into Practice4 • Summarize the evidence • Identify local barriers to implementation • Measure performance • Ensure all patients receive the intervention • Engage, educate, execute, evaluate • Educate staff on the science of improving patient safety

  28. LeadingChange with the 4 E’s

  29. Implementation: Starting with 4 E’s Strategies will depend on YOUR Stakeholders Senior executives Engage Educate Win the hearts & minds of your team(s) Execute Teach your team(s) about your intervention Evaluate Implement your plan with purposeful team participation Team leaders Determine how well your effort has improved care processes & outcomes Frontline staff

  30. Key Partnerships To help with 4E’s, choose partners: • 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

  31. an engaged It takes a village I have all these powers, but no one listens to me!

  32. Engage • 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

  33. FosteringEngagement Activity: List several examples of both intrinsic and extrinsic motivators. Intrinsic motivation Internal, psychological rewards that derive from the work itself Extrinsic motivation External rewards or incentives attached to the work

  34. CelebratingOur Heroes

  35. Educate • 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 team Activity: Any other examples of ways to educate staff members?

  36. Execute: The Principles of Safe Design6 • Standardize what is doneand 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. 36

  37. Briefings and Debriefings • 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

  38. Briefings & Debriefings It is essential to adapt tools to the local environment. • No follow-up on comments • Too long • Same form used in all OR’s (neurosurgery, ortho, general surgery)

  39. “Real time” Identification of Defects11 • Customize form based on your specific needs • Add your components to the bundle • Address defects with infrastructure & communication • Log defects

  40. Debriefing Defect Logbook

  41. Example of Defects Addressed: Instruments Problem Conflict 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

  42. 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?

  43. Evaluate 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 • 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.

  44. Colorectal SSI Rate by Quarter (NSQIP) Baseline Year 1 Year 2 Year 3 SSI Rate: 27% SSI: 17% SSI Rate: 20% SSI Rate: 11%??

  45. 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 Engage Educate Execute Evaluate

  46. Recapof 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.

  47. 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?

  48. ContentCallEvaluation We want to ensure that the content calls provide useful and pertinent information for the SUSP teams. For this reason, we request that you complete a brief evaluation following each call. The evaluation may be found at the following link: https://www.surveymonkey.com/s/cohort4_Implementation1

  49. References • CrollaRM, 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. • 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 CollSurg2011;215:193-200. • 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. • Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large-scale knowledge translation. BMJ 2008;337:963-965. • 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

  50. References • Pronovost PJ, Goeschel CA, Marsteller JA, Sexton JB, Pham JC, Berenholtz SM. Framework for patient safety research and improvement. Circulation 2009;119:330-337. • 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. • 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. • Berenholtz SM. Et al. Implementing standardized operating room briefings and debriefings at a large regional medical center. JtComm J QualSaf. 2009;35(8):391-397. • Haynes AB. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med.2009;360:491-9. • Bandari J. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical cneter. JtComm J QualSaf 2012;38(4):154-160

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