Using Evidence-Based Interventions and the
Surgical Unit-based Safety Program (SUSP) to
Reduce Surgical Site Infections and other
Surgical Complications: A National Project to The Armstrong Institute for Patient Safety and Quality
Improve Surgical Outcomes
About the Project
Nearly 50 million people have surgery each year
in the U.S., approximately one million develop
serious complications and over 150,000 patients
die within 30 days. The Agency for Healthcare
Research and Quality (AHRQ) is funding a national Surgical Unit-based Safety Program
(SUSP) to reduce surgical site infections (SSI)
and other surgical complications.
Benefits
Proven Methods To improve surgical care requires
three pillars: performance measures clinicians believe
are valid, methods to engage front-line clinicians and
hospital leaders and ensure patients receive evidencebased therapies, and a process to improve teamwork,
safety culture, and learn from mistakes. This program
will provide these pillars and build on the approach
that led to large-scale successful improvement efforts
such as the Michigan Keystone ICU program, the national program to reduce central line associated blood
stream infections (CLABSI), and international efforts
to improve quality of care including the World Health
Organization Safe Surgery Saves Lives campaign.
Project Sponsor and National Project Team
This project is sponsored by AHRQ, and includes.
faculty time, training materials, standard reports and
national networking across the project teams. The
National Project team includes world renowned experts from AHRQ; The Johns Hopkins Medicine
Armstrong Institute for Patient Safety and Quality
led by Dr. Peter Pronovost; the American College of
Surgeons led by Dr. Clifford Ko; Dr. Charles Bosk;
and his team from The University of Pennsylvania,
and the World Health Organization Patient Safety
Programme (PSP). In addition, the National Project
Team includes faculty who helped develop and implement the Department of Defense and AHRQ
funded TeamSTEPPS program.
Key Interventions
SSI reduction remains an elusive goal. This is understandable; SSIs are multifactorial in etiology and a
single ‘SSI Prevention Bundle’ is unlikely to reduce
SSIs. Together, we can reduce SSIs.
In this program, we will work together to:
Comparative Data that are valid and feasible
Evaluating surgical outcomes is challenging and
complex. Our partner, the American College of Surgeons (ACS), runs the National Surgery Quality
Improvement Program (NSQIP). Initially funded by
AHRQ, NSQIP collects robust data on surgical
complications and outcomes using rigorous quality
control. Participating hospitals will receive real-time
individual and comparative reports to track progress
towards improving surgical care. All hospitals will
benefit from the rich data collected by NSQIP, but
hospitals do not need to participate in NSQIP to be
in this project. In fact, most hospitals in the project
will not be NSQIP participants.
1.
National Project Goals
 To achieve significant reductions in surgical
site infection and surgical complication rates.
Project will focus on one outcome measure:
SSI rate; one process measure: use of checklist like methods to improve surgery safety
(briefings/debriefings), and a measure of
safety culture: Hospital Survey of Patient
Safety (HSOPS).
 To achieve significant improvements in safety
culture.
5.
2.
3.
4.
6.
Review, adapt and implement the World Health
Organization Safe Surgery Checklist.
Review other tools focused on improving adherence with evidence-based practice and explore
opportunities to implement selected tools based
on the types of defects identified by participating
sites.
Review, adapt and implement the Comprehensive
Unit-based Safety Program (CUSP) and selected
TeamSTEPPS tools to improve teamwork, communication and safety culture.
Review emerging evidence for the prevention of
SSI and explore opportunities to implement selected interventions based on local resources and
culture.
Help participating sites gain ‘ground truth’ by
tapping into the wisdom of frontline staff and
conducting several time-limited audits to identify
defects in care processes that may be contributing
to SSI within their hospital.
Explore opportunities to prevent other surgical
complications, including retained foreign objects,
wrong sided surgery,
ACTION II Quarterly Digest
Using Evidence-Based Interventions and the
Surgical Unit-based Safety Program (SUSP) to
Reduce Surgical Site Infections and other
Surgical Complications: A National Project to The Armstrong Institute for Patient Safety and Quality
Improve Surgical Outcomes
Armstrong Institute ACTION II Partnership
October 2011
Program Requirements
(Partnership Call notes continued)
Opportunities to Participate:
Coordinating Organizations (State Hospital
We are recruiting coordinating entities now,
Topics
of discussion:
Associations,
HENS, Regional Organizations,
with a goal of project launch in late spring.
etc…): commit to funding and coordinating monthly
Hospital engagement networks (HENS), state
team
VTE
the surprisingly
number
of orders that
go unused.
This(SHAs)
area needs
to be
callsprophylaxis
and annual and
face-to-face
meetings (or
a
hospital
associations
and other
state/
explored,
especially
since
VTE
is
so
tied
with
readmissions.
This
is
a
great
topic—and
something
suitable alternative).
regional /system level safety groups are eligible
that could be forwarded up as a concept
to enroll as a coordinating entity. HENS may
use this to meet previously specified contract
Hospital
Would
units:
Canada
commit
be to
able
participation
to be involved?
for 24 We are currentlyexpectations.
just putting together planning and
months
and:
recruitment,
and having WHO involved, and making a case of why you should be involved should
to launch
the program
a cohort
be enough. AHRQ said we needed a number of states, We
andaim
I doubt
they would
balk atwith
including
of hospitals from 10 states or Hospital Engage more.
Assemble a multidisciplinary team to include
ment Networks (HENS). We will focus on
team members from surgery, PACU (postACS/NSQIP
hospitals first
since
they haveand
 ISMP
is working
on development
of technology and software
with pharmacists
and
dispensing
Anesthesia
care unit)
and the medical/surgical
readily
baselinethis
data.further
In Falloffline!
2012 we
unit. like to carry it over to acute care. This sounds great
would
and available
we can discuss
will begin enrolling non-NSQIP hospitals and
 Identify an executive sponsor for the project and
additional
states orsafety
HENSefforts
in the program.
 Looking
at the
methods/interviews/surveys
at engaging physicians
in patient
– I’d likeThe
meet with
executive monthly.
overarching
goal
is
that
a
majority
hospitals
how
do this?
When you
don’t have time dedicated to this, it is very hard, of
and
we
 feedback
Regularlyon
meet
as to
a team
to implement
intervenin
all
states,
the
District
of
Columbia
and
were
of looking
at both employed and non employed in/out patient to engage and motivate
tions thinking
and monitor
performance.
Puerto Rico will participate over the course of
in patient
and safety
improvement efforts.
 physicians
Participate more
in annual
face-to-face
meetings,
the project.
weekly immersion calls, and monthly content
 Medication
errors
and coaching
calls are published quarterly by ISMP, and sent out and given to safety committees to
assess
and
make
 Implement selectedassignments.
audit tools, the World Health
Interested in enrolling or learning more?
Organization Safe Surgery Checklist, and other
 AHRQ’s
basedcare.
practice center currently working
reports
for patientatsafety.
There OR
selected evidence
tools to improve
ContactonDr.
Lisa Lubomski
410.614.4037
would
be
great
synergy
with
EPC.
How
could
we
best
accomplish
this?
Perhaps
even
have
 Implement CUSP to improve teamwork, comwebinars
soand
people
listen in.
munication
safetycan
culture.
Email: [email protected]
 Submit minimal set of standardized surgical outIf you missed the call, don’t fret! Chris Goeschel plans on having a follow up call since the call
come data monthly.
happened to coincide with another national meeting that occurred.
 Administer the AHRQ HSOPS culture survey
annually and use results to inform site specific
improvement targets
 Share what you are learning with other participating sites
Other Items!
 Last week, Tuesday, October 18th, 11am EDT, we had our
TOO Kick off Call
 We will work on releasing future RFTOs within 1-2 days
after receipt to partners!