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

2. Some quick administrative announcements 2 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 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

3. Polling Question 3 What is your role in your clinical area?  Surgeon  Quality Improvement practitioner  Infection preventionist  OR nurse  OR technician  Anesthesiologist  OR manager  Educator  Other Draft-Pending AHRQ Review

4. Learning Objectives 4 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. Draft-Pending AHRQ Review

5. Polling Questions 5 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 Draft-Pending AHRQ Review

6. SSI Bundle Characteristics 1,2,3 6 A collection of evidence-based practices Tailored to your environment 5 to 7 elements Dynamic and evolving

7. No single SSI prevention bundle? 7 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

8. Three Ways to Surface Defects: Review 8 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 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 Draft-Pending AHRQ Review

9. TRANSLATING EVIDENCE INTO BEDSIDE PRACTICE 9

10. Translating Evidence into Practice 4 10 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 Draft-Pending AHRQ Review

11. 11 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 Translating Evidence into Practice 4

12. 12 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 Draft-Pending AHRQ Review

13. 13 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. Use the BIM Tools as a guide! Download from the SUSP website: https://armstrongresearch.hopkinsmedicine.og/susp/ssi/resources.aspx. Draft-Pending AHRQ Review

14. 14 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. Use the BIM Tools as a guide! Download from the SUSP website: https://armstrongresearch.hopkinsmedicine.og/susp/ssi/resources.aspx.

15. 15 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?

16. 16 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 Draft-Pending AHRQ Review

17. Factors Barriers Potential Actions CLINICIAN Knowledge of the guideline Does the clinician know how to comply with the guideline? Attitude regarding the guideline Does the clinician believe that following the guideline will reduce infection rates? Current practice habits What does the clinician currently do (or not do)? Perceived guideline adherence How often does the clinician do everything right? Identify the Barriers: BIM Tool Guideline: Data collection mode (Check one): Observe the Process  Discuss the Process  Walk the Process  Investigator:Shift: 17 Draft-Pending AHRQ Review

18. Factors Barriers Potential Actions WORK ENVIRONMENT Task Who is responsible for following the guideline? Tools & technologies What supplies & equipment are available/used? Administrative support How does current administrative support affect adherence? Performance monitoring/feedback How do clinicians know they are following the guideline? Perioperative culture How does the perioperative culture affect adherence? Identify the Barriers: BIM Tool 18 Draft-Pending AHRQ Review

19. 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 Likeliho od Score Severi ty Score The higher the Barrier Priority Score for a barrier, the more critical it is to eliminate or decrease the effects of that barrier. 19 Draft-Pending AHRQ Review

20. Selected Actions Performance Measures Who’s in charge of these efforts? Follow-up date Develop a BIM Action Plan 20 Draft-Pending AHRQ Review

21. Translating Evidence into Practice 4 21 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 Draft-Pending AHRQ Review

22. Measure Performance: Auditing Resources 22 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.

23. 23 https://armstrongresearch. hopkinsmedicine.org/ susp.aspx Measure Performance: Portal Resources

24. 24 Measure Performance: Portal Resources Draft-Pending AHRQ Review

25. 25 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 Draft-Pending AHRQ Review

26. 26 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 Translating Evidence into Practice 4

27. LEADING CHANGE WITH THE 4 E’S 27

28. Implementation: Starting with 4 E’s 28 Senior executives Team leaders Frontline staff Engage Educate Execute Evaluate 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 Draft-Pending AHRQ Review

29. 29 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 Draft-Pending AHRQ Review

30. 30 I have all these powers, but no one listens to me! It takes a village an engaged

31. Engage 31 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 Draft-Pending AHRQ Review

32. Fostering Engagement 32 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. Draft-Pending AHRQ Review

33. 33 Celebrating Our Heroes Draft-Pending AHRQ Review

34. Educate 34 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 Inservices 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 & team Activity: Any other examples of ways to educate staff members?

35. Execute: The Principles of Safe Design 6 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# https://armstrongresearch.hopkinsmedicine.org/susp.aspx# Principles apply to BOTH technical tasks and teamwork.

36. Briefings and Debriefings 36 Reductions in communication breakdowns and OR delays 7 Reductions in procedure and miscommunication-related disruptions and nursing time spent in core 8 Improved communication and teamwork, feasible given current workload 9 Reductions in rate of any complications, SSI and mortality 10

37. It is essential to adapt tools to the local environment. 37 No follow-up on comments Too long Same form used in all OR’s (neurosurgery, ortho, general surgery) Briefings & Debriefings Draft-Pending AHRQ Review

38. “Real time” Identification of Defects 11 38 Customize form based on your specific needs Add your components to the bundle Address defects with infrastructure & communication Log defects Draft-Pending AHRQ Review

39. Debriefing Defect Logbook 39 Draft-Pending AHRQ Review

40. Example of Defects Addressed: Instruments 40 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 Impact Instruments available when needed Draft-Pending AHRQ Review

41. 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? 41 Draft-Pending AHRQ Review

42. Evaluate 42 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 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 Draft-Pending AHRQ Review

43. Colorectal SSI Rate by Quarter (NSQIP) 43 Baseline Year 1 Year 2 Year 3 SSI Rate: 27% SSI: 17% SSI Rate: 20% SSI Rate: 11%

44. Summary 44 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 Draft-Pending AHRQ Review

45. Recap of Learning Objectives 45 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. Draft-Pending AHRQ Review

46. Discussion Questions 46 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? Draft-Pending AHRQ Review

47. References 47 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 Draft-Pending AHRQ Review

48. 48 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 Draft-Pending AHRQ Review