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

2. Learning Objectives Provide an overview of the Georgia SUSP Program
Outline requirements and expectations
Delineate the process to join the collaborative
Describe next steps

3. 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

4. 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.

5. 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

6. 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

7. 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

8. Model for Improvement

9. Implementation Framework

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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.

16. 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.

17. Measures and Dates

18. 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 or fax
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

19. Questions?

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