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

Learning Objectives Provide an overview of the Georgia SUSP Program Outline requirements and expectations Delineate the process to join the collaborative 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

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 check- list 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 5 February 7 SUSP Overview 2 February 12 February 14 Building Your SUSP Team, Part 1 3 February 19 February 21 Science of Safety 4 February 26 February 28 CUSP 5 March 5 March 7 SSI Prevention 6 March 12 March 14 Building Your SUSP Team, Part 2 7 March 19 March 21 Assessing Patient Safety Culture 8 March 26 March 28 SUSP Data Platform 9 April 2 April 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

Next Steps Review the materials with Senior Executive Make commitment to participation in the project Have the CEO (or designated Senior Executive) sign the Commitment Form and send to Denise Flook at dflook@gha.org or fax 770-249-4591 Develop a basic clinical team and send in Clinical Team Participant Agreement. Forms should be sent ASAP or no later than Feb 8 if possible. Listen to onboarding calls

Questions?

Denise Flook dflook@gha.org. 770-249-4518 Contact Information Denise Flook dflook@gha.org. 770-249-4518