A perioperative safety and quality change management model and case study: Muda Health

Introduction

The surgical space is a high-risk environment where hazards lurk around every corner and for every patient. The patients who come to surgery are generally among the sickest and at more advanced stages of disease. The very act of treatment involves risky interventions that are often considerably invasive with vigorous and unpredictable physiologic responses. The level of complexity, both in task-oriented and cognitive demands, results in a dynamic, unforgiving environment that can magnify the consequences of even small lapses and errors and undermine patient safety.

The lifeblood of a hospital's revenue cycle is having well-orchestrated perioperative services as these services typically generate around 60% of overall hospital revenue. The operating room (OR) is one of the most complex and challenging areas, and value streams with multiple inputs and outputs ( Fig. 15.1 ). Due to the revenue impact of perioperative services, hospital leadership desires to ensure that perioperative services are well managed by achieving constant readiness, improving workflow, maximizing throughput, and ensuring surgery is performed in the safest environment for the patient.

This case study is based on the work at a Level One trauma healthcare system during the years 2020–22. We have changed the name to Muda Health (MH), part of the MH system, with a suburban and rural market presence. The work was sponsored by MH hospital leadership along with the engagement of surgical and nursing clinicians, quality management and infection control staff, and guided by external quality improvement and system change consultants. ¹

1 https://jbarainnovation.com .

The project was initiated due to increased surgical adverse safety events, inefficient services, low national quality ratings, and surgical site infection rates above the national averages.

The case study describes the transformation efforts, provides an overview of the new governance structure put in place to facilitate the transformation, details the methods, tools, and analytical approaches to the safety management of perioperative services, and discusses the results of the transformation efforts. The purpose of the transformation was to engage leadership and staff by leading, facilitating, and lending real-time support to ensure nurses and surgeons are teaming up in a highly aligned collaborative environment. The external facilitation challenge was to empower front line staff to work and deliver improved surgical outcomes, making the hospital more efficient, and leading to increasing levels of patient and staff satisfaction.

Case study

What was done?

We used the Assessment–Discovery–Action–Manage–Sustain (ADAMS) framework in the case study ( Fig. 15.2 ):

• a)

  Assessment

  • a.

    Evaluated key organizational, strategic, and structural elements of the surgical services, ensured alignment of the baseline governance structure/ leadership/operating performance with desired goals of developing highly reliable perioperative services delivery.

  • b.

    Identified and explored the factors that impede stable perioperative workflow.

• b)

  Discover

  • a.

    Built consensus of the practices that help optimize OR team performance.

  • b.

    Brokered agreement on a new governance structure that will facilitate improvement in quality and patient/staff safety, cost/margins, and timeliness of delivery.

• c)

  Action

  • a.

    Deployed a system of scorecards (high-level outcome measures) and dashboards (process performance measures) for quality/safety, cost (margin enhancement), time (surgical services throughput) that form the basis for improved decision-making.

  • b.

    Empowered physicians and staff to improve and innovate flow using a coaching model that used new teams that oversee the following:

    • i.

      Presurgical process–we call the “before” phase,

    • ii.

      During surgery process–we call the “during” phase,

    • iii.

      Postsurgical process–we call the “after” phase.

  • c.

    Provided a forum for receiving feedback and suggestions from other hospital stakeholders that support or benefit from the successful outcomes of surgical services (e.g., radiology, pathology, facilities, nursing units, ICUs, supply chain management, quality department, facility management, patient scheduling). A formal team called the “Voice of the Staff Team” (VST) was created to gather the feedback and suggestions that could be discussed and then relayed anonymously or without fear of retribution to the senior leadership team (SLT) and the BDA (Before/During/After) teams.

  • d.

    Required the SLT to provide a structured forum to regularly (e.g., biweekly or monthly) receive updates from the BDA teams and VST regarding accomplishments since the previous forum meeting, anticipated next steps, along with challenges they face for which they seek leadership support and actions.

• d)

  Manage

  • a.

    Hospital and Physician Leadership agreed to take on the challenges to success that were identified by the BDA teams and VST so as to remove barriers to success.

  • b.

    Deployed ongoing monitoring to ensure improvement and innovation efforts are borne out by the scorecards/dashboard system developed and put in place. Note: Scorecards provided outcome measures for all of perioperative services, while dashboards provided process and outcome measures for particular processes corresponding to the Before–During–After surgery processes.

  • c.

    Held regular board and leadership review of perioperative services quality and safety efforts and results.

• e)

  Sustain (Planned to be done in the future)

  • a.

    Translated the governance structure for perioperative services to other service lines in the hospital including emergency medicine, women's and children services, outpatient diagnostic services including radiology and pathology, etc.

  • b.

    Trained and engaged hospital staff and physicians in TeamSTEPPS training to enhance the transformation to a High Reliability Organization (HRO) for all MH Hospitals.

  • c.

    Maintained a “parking lot” of project opportunities to improve/innovate that can be prioritized in order to sanction future projects to enhance MH ability to further drive its mission.

High reliability organization (HRO) framework for surgery quality improvement ( Fig. 15.3 )

HROs have characteristics that parallel many features of the surgical environment, including the use of complex technologies, a fast-paced tempo of operations, and a high level of risk, yet they have spectacularly low error rates. HROs are required to respond to a wide variety of situations under changing environmental conditions in a reliable and consistent way. The “pillars” of success for surgical process improvement are highly dependent on the interpersonal and group dynamics relative to communication, teamwork, shared goals, and an environment that fosters a “policy of no surprises” and zero defects. Mutual respect and shared responsibility are predicated on radical transparency of data and team performance, truth telling even when the news is not positive, and staff having psychological safety to speak up and out about safety concerns. They also use shared goals and knowledge of improvement to sustain a learning and trusting community. ²

2 The more I know, the less I sleep, global perspectives on clinical governance. Lead author Berg M, Barach P, et al. KPMG Global Health Practice. 2013.

Perioperative services depend on several communication handoffs including to and from inpatient floors and outpatient services, between physicians and nurses, in preop, surgery, PACU, tech staff and management, etc. Extensive research estimates that improving communication tools or methods can lead to an improvement of 80%–90% in patient handoffs and in surgical quality performance. ³

3 Sanchez J, Barach P. High reliability organizations and surgical microsystems: Re-engineering surgical care. Surg Clin 2012; 92 (1):1–14. https://doi.org/10.1016/j.suc.2011.12.005 .

In this case study, the deployment of HRO methods facilitated the improvement of a surgical safe culture at MH that got more accustomed to “telling the truth” and addressing process variation in services or patient harm issues quickly and resolutely. Improvements in communication may lead to a significant level of quality performance improvement. ⁴

4 Amalberti R, Auroy Y, Berwick DM, Barach P. Five system barriers to achieving ultra-safe health care. Ann Intern Med 2005; 142 (9):756–764.

We used a just-in-time training approach with regular refresher drill downs as needed in concert with the Before–During–After (BDA) teamwork ( Fig. 15.4 ) to enhance the HRO deployment, increasing awareness and engagement of leadership and BDA team members to address deployment deficiencies. We introduced the nationally acclaimed training program, TeamSTEPPS, a set of “Strategies and Tools to Enhance Performance and Patient Safety,” ⁵

5 Baker D, Battles J, King H, Salas E, Barach P. The role of teamwork in the professional education of physicians: current status and assessment recommendations. Joint Comm J Qual Saf 2005; 31 (4):185–202.

to MH clinicians and staff through an online and in-person curriculum delivery supported by a dedicated project intranet website. This included role playing, case studies, and involvement of hospital personnel in enhancing both HRO and teamwork methods. The communication topics included active listening, empathic communication, interprofessional learning, conflict engagement, negotiation and relational coordination. ⁶

6 https://heller.brandeis.edu/relational-coordination/about-rc/index.html .

How was the quality improvement activity implemented?

MH recruited a multidisciplinary team of surgeons and other surgical team members, infectious disease specialists, and an antimicrobial stewardship pharmacist to create a core QI team and to conduct an initial analysis and identify opportunities for improvement. Problem characterization early is key ( Box 15.1 -Problem Statement) through fishbone analysis and process mapping, Supplier–Input–Process–Output Customer (SIPOC) analysis and Point-of-Pain analysis revealed that creating a clear, evidence-based guideline for surgical site infection mitigation and improved surgical flow required consistent definitions ( Figs. 15.5 and 15.6 ).

Getting started. The team anticipated that acceptance and implementation of a new practice guideline with a large group of private practice surgeons and anesthesiologists working in surgical teams would be challenging. MH identified and engaged key stakeholders including nurses, physicians, pharmacists, and administrators through education sessions and regular team rounds led by MH surgical QI team leads and the consultant team. Teams agreed on clear and measurable goals (see Box 15.2 -Goal Statement). All stakeholders were provided with an opportunity to raise their “points of pain,” review, and provide early, often, and ongoing feedback throughout the project ( Fig. 15.7 ). The MH core QI team met weekly to monitor progress through the cycles, sought feedback, to ensure success with implementation. The consulting team reviewed the literature as well as guidelines from other institutions and interviewed and surveyed MH clinicians. This information was used to create practice recommendations.

A focus was placed on reducing potential safety risks that contribute to adverse events, infections, delays, and returns to the OR. In doing so, we utilized a team of Infection Prevention, Quality, Risk Management, and Operating Management personnel who implmented the initiative. An emphasis was placed on reinforcing risk management, sterilization techniques, proper hand scrubbing, and patient flow optimization as the patient moved through all phases of the surgical service line. Traffic in and out of the individual operating suites was minimized and monitored with door counters. Vendors were monitored to ensure scrubs were changed, movement in and out of the operating suite was reduced, and a reeducation program was reiterated to not violate the sterile field and to reduce unnecessary traffic in and around the perioperative suites (correlated with patient infection rates). Descriptive statistics were used to describe baseline data. Outcome and process measures were evaluated using statistical process control charts with signals, indicating special cause, were identified by using standard control chart rules ( Fig. 15.8 ).

Description of the quality improvement activity

The consulting team used a multiphased approach called ADAMS ( Fig. 15.2 ) and the projet was run out of a dedicated situation room (“war room”) as seen above. The continuous improvement strategy included a series of Plan-Do-Study-Act (PDSA) cycles. ADAMS served as a model that hospital leadership was able to leverage to stage the deployment of a safe and “just culture” that consistently builds political capital by increasing staff and patient buy-in to support the deep drive toward achieving the quadruple time at MH. The ADAMS model approach was deployed through two phases ( Fig. 15.2 ):

Quality guiding principles adopted by Muda Health leadership and staff

Transforming complex surgical services first requires agreement by leadership, clinicians, and staff on the guiding principles of the QI project. MH held numerous town hall and department meetings facilitated by the consultants in which the following essential “pillars” were agreed upon to help MH facilitate a successful surgery quality improvement effort including the following:

• 1)

  Accountability and responsibility

  • a.

    Establish cross-level and cross-functional accountabilities and responsibilities for taking positive steps toward improving perioperative performance.

  • b.

    Plan clear and accountable timetable for the perioperative quality improvement project.

• 2)

  Data Transparency

  • a.

    Process data would be shared with all project members in meetings, online, using data dashboards available in new perioperative wall monitors.

• 3)

  Decision-making

  • a.

    Foster a transparent decision-making process and culture that is data driven and aligned with MH system values.

• 4)

  Teamwork

  • a.

    Ensure all project levels are working together to implement changes that will drive performance improvement benefiting patients/families, MH, staff at all levels across perioperative services, and physicians.

• 5)

  Communication and discussion

  • a.

    Encourage input from all levels within the organization so as to increase buy-in from all involved in perioperative service delivery.

  • b.

    Build trust through clear and honest “truth telling” that is focused on facts not personalities, and that involves all staff levels within the hospital including nonemployed staff and physicians.

• 6)

  Change management

  • a.

    Recognize that change is difficult although necessary, therefore, participation and buy-in by all individuals and teams involved is required and ongoing.

• 7)

  Keeping score ( Fig. 15.18 )

  • a.

    Define current state performance as the baseline against which future performance is compared using agreed upon metrics.

  • b.

    Enhance a data-driven performance tracking system that focuses on quality, cost, and time scorecards (e.g., high level often lagging indicators) and dashboards (e.g., proxy real-time measures at the process detail level linked to the scorecard indicators).

  

• 8)

  Shared goals and goal setting ( Fig. 15.19 )

  • a.

    Establish and commit to shared goals within the hospital in collaboration with nonemployed staff including physicians.

  • b.

    6-month and 12-month targets established in terms of quality, cost, time indicators.

  • c.

    Set targets for weekly and monthly improvements in Before Surgery–During Surgery–After Surgery processes (i.e., simpler terminology for preoperative, intraoperative, postoperative processes).

  

• 9)

  Strategic project deployment

  • a.

    Prioritize and cascade projects within Before/During/After surgical processes to ensure what needs to be done first while laying the foundation for ongoing future projects.

  • b.

    Honest and accountable resourcing of projects in terms of staff time and budget support.

  • c.

    Identify and engage Champions and leaders for the Before/During/After surgical projects.

• 10)

  Policy of No Surprises

  • a.

    Ensure that all key data are transparently shared especially when they portend to risky, and costly impacts.

  • b.

    Ensure all surgical staff members are involved and participate in consensus decision-making processes allowing for individuals to agree or disagree in order to work together toward buildng support for implementing decisions.

New governance structure and timeline for perioperative services transformation (Appendix I, II, III, IV, V)

Significant surgical QI projects require alignment of governance and values to ensure the project obstacles are addressed early and clearly. A Perioperative Services Leadership Steering Team (LST), comprised of senior executives and physician leaders, was established to drive safety and improvement across the perioperative services. To increase the opportunity to involve more staff in the transformation, the consulting team facilitated the initiation of a cross-function Voice of the Staff (VST, which was built on MH foundational belief that “change is not what we do to people” rather “change is what we do with people.”

The VST members were selected using the following guidelines:

• cross-functional, cross-level of representatives from various surgical service line functions with the only restriction being the level of those from perioperative services department being no higher than manager.

• viewed as respected peers and colleagues.

• known to be focused on what is in the best interest of MH staff and patients.

• not afraid to voice their opinions.

• those that peers seek out for help or support.

The VST team was expected to meet biweekly with subgroups of participants that meet daily in huddles. By having both the LST and a VST in place, meeting regularly, tracking relevant metrics, and transparently addressing issues helped to foster communication and trust across, down, and up within the organization. Needed improvements in culture were incorporated such as having a supportive environment to ensure positive engagement of all staff, volunteers, patients, and families in truth-telling, speaking up when poor behaviors were exhibited and seriously considering positive suggestions. The goal was for MH to increase ownership, employee engagement, and accountability at all levels.

The BDA teams were established to identify and implement improvements using various performance improvement (PI) methods, for example, via:

• “Do Its”:

  • Obvious or easily understood changes to be quickly implemented.

  • Waste points identified in the process that can be reduced or eliminated.

• Rapid Improvement Events (RIEs)—called Kaizen Events:

  • A Kaizen event may totally change many process steps or the entire process

  • Bottlenecks or failure points are identified with solutions developed.

  • Remove bottlenecks that inhibit process flow efficiency/effectiveness.

• PDSA (Plan–Do–Study–Act) cycles:

  • Continuous process improvement cycles used for ongoing process learning and change.

  • Process owners and participants continually seeking ways to improve.

  • Deploy analysis tools to better understand the process data.

• Lean Six Sigma:

  • More advanced qualitative and quantitative tools to develop solutions.

  • Solutions are typically not obvious and require more process study.

  • May involve several steps in the process.

The governance structures in Figs. 15.4 and 15.12 depict the reporting relationships of the newly created project leadership teams.

Designing the new workflow

It is well known that for many hospitals the emergency department is often viewed as the “front door” to the hospital as many patients' first encounter with a hospital is through personal or family visits originating in the emergency department. For many others, their early encounters with the hospital are through outpatient or elective surgeries. Data show that 60%–80% of patients have their first encounter with the hospital through the emergency department or through outpatient/elective surgeries.

What might this mean for MH? The patient experience/satisfaction metrics are likely highly influenced by the hospital performance of the emergency department leading to the perioperative services. In this section, we will discuss the subprocesses that represent components of the period of time before the patient enters the OR. The following components are not meant to be a detailed and exhaustive list:

Admissions into surgical services

• Hospital admissions for inpatient stays.

• Emergency department transfers either directly to inpatient areas or to the surgical department (e.g., trauma cases).

• Outpatient arrivals and admissions.

Internal transitions

• Transportation from inpatient settings to surgical department.

• Patient arrival to outpatient registration.

• Signing patient/legal guardian consent forms.

• Outpatient registration to patient surgical preparation.

Patient family/friends care

• Family/friends waiting areas and comforting environment.

• Communication or information regarding patient status.

• Availability or proximity to access for food or beverages.

Scheduling of staff and surgical suites

• Physician/practice input as to preferred schedule or block times.

• Schedule constraints of surgeons, anesthesiologists or anesthetists, surgical nurses and techs, environmental engineering staff, sterilization staff/techs, others.

• Schedule constraints due to equipment availability, supplies, sterilized packs/trays.

• Add-on policies and enforcement.

• Trauma schedule impact mitigation policies.

Supplies

• Supply choice and purchase guidelines.

• Surgeon preference cards and consistency with supply policies among physicians, hospital supply chain management, and sterilization staff.

• “Just in Case” versus “Just in Time” supply management balance.

• Obsolescence policies for supplies.

• Supply disposal processes.

• Supply storage, infection control/management.

• Capital expense policies.

• Consumable expense policies.

Sterilization

• Preference card management policies.

• Add-on lead time policies and enforcement.

• Sterile process lead-time guidelines and enforcement.

• Sterile pack utilization policies and processes to minimize lack of pack/tray utilization.

• Processes to address sterile equipment demand conflicts.

• Collaboration with infection control to reduce surgical site infections (SSIs).

• Sterilization staff input (voice of sterilization) requested and considered by physicians and surgical staff in managing surgical demands and timelines.

• Weekday and weekend staffing process. The staffing HR dashboards showed between 30% and 40% of OR staff—nurses, technicians, and nursing aids were agency staff.

Surgical preparation

• Core measure policies enforced (e.g., administration of antibiotics before “first cut”).

• Patient safety policies enforced.

• Patient communication/comfort checklist followed prior to anesthesia.

  • Patient consent forms signed.

  • Patient needs addressed.

  • Reason for surgery verified if possible

• Patients moved to OR suite (wheels up) 5 min before scheduled start.

Physician preparation

• Physicians prepped at least 5 min before scheduled start of case defined as entering in the OR.

• Surgeon present at anesthesia administration as required by the joint commission.

• Presurgical checklists completed.

In summary, the before surgery components are key in setting the stage for reliable surgical outcomes along with detailed consideration of the patient/family/friends' experiences. Poor scheduling and adherence to policies for scheduling including add-ons, rushing/skipping over checklist elements, poor teamwork among the employed and unemployed staff, poor supply, and sterilization management, and otherwise any lack of preparation can lead to shoddy teamwork, bruised egos, poor surgical outcomes, and ultimately-litigation.

Keeping score—construction of the data scorecards and leadership dashboards

During the summer of 2020, The Leapfrog Group, a nonprofit organization that provides consumers with an assessment of the quality performance of hospitals nation-wide, reported ( https://www.leapfroggroup.org ) that the surgical site infection (SSI) rate at MH had declined from a grade of “B” to a grade of “D.” The Leapfrog national grade was matched by the Centers for Medicare and Medicaid Services report of two stars (out of five stars) for MH. ⁷

7 CMS uses a five-star quality rating system, with 5 being the highest, to measure the experiences Medicare beneficiaries have with their health plan and health care system.

The public perception and reputation of a hospital can be impacted by outside reports and patient stories. Creating an internal scorecard system that represents performance outcomes along with a dashboard system of internal process performance can help support the change management efforts. It was decided that these two systems could be utilized to help MH prioritize and direct process improvement efforts that could positively improve outcome performance.

Key components of a balanced scorecard approach

The MH operations plan outlined the key strategy, priorities, areas of responsibility, and critical performance measurements through responsible leadership and team performance focused on measurable areas. Critical plan components included strategy, deliverables, performance indicators, and organization change. The key components for the MH surgical services plan included the following:

• Operating plan strategy: Understand why and how the targets will be met.

• Deliverables: Know the performance measurement targets.

• Performance indicators/measurements: Show how to meet targets.

• Organization: Understand who is accountable for targets.

The scorecards represent outcome measures that the LST must manage and oversee. The dashboards represent process measures associated with the BDA aspects of perioperative services. For example, an SSI rate is an outcome measure that is impacted by the quality of the handoffs within perioperative services, performance to core measures such as antibiotic administration less than 60 min before first surgical incision, infection control processes, sterilization of equipment, management of sterile fields, effectiveness of surgical timeouts, and many other factors. All these factors can be measured and represented as possible dashboard metrics. If the dashboard metrics continue to show poor results over time, then the SSI rate at the scorecard level will be impacted.

The metrics should be impartial to ensure trustworthiness of quantifiable results, and should match the leadership concentration areas of MH. However, a critical focus on key concentration areas and requirements can enhance patient safety, surgical services and financial objectives. Metrics have to be viewed as reliable sources of data . The MH surgical performance metrics should ensure alignment with the MH corporate financial performance targets and link to the MH clinicians and staff performance.

In general, the LST needs to be accountable for the scorecard metrics, while the BDA teams provide ongoing (e.g., weekly) reports regarding the dashboard metrics (Appendix VI) using agreed upon project charter worksheets ( Fig. 15.20 ). The BDA teams can more quickly highlight positive performance improvement and similarly address downturns in performance by understanding variance in the dashboard performance metrics ( Fig. 15.21 ).

The major categories for scorecards and dashboards along with some examples are as follows:

• Quality

  • Scorecard example—SSI rate, infection control metrics.

  • Dashboard example—Core measure for antibiotic administration.

• Cost/Margin

  • Scorecard example—Ratio of surgical inventory relative to surgical revenue.

  • Dashboard example—Ratio of obsolete surgical inventory to all surgical inventory.

• Time/Timeliness of Delivery/Throughput

  • Scorecard example—Number of outpatient/inpatient surgeries performed per week or month.

  • Dashboard example—Lead time from patient arrival to patient preop complete.

The LST oversees the scorecards for quality (e.g., SSI), cost, and time metrics. As the scorecard metrics are typically high-level outcome metrics, each of the BDA teams will use a dashboard of quality, cost, and time process metrics that are related to the scorecard metrics. The BDA teams are responsible for focusing their efforts on improving the dashboard metrics which in time are expected to positively impact the scorecards that the LST is overseeing (Appendix VI) ( Figs. 15.22–15.24 ). The three figures represent three types of work assessments.

Keep in mind that data scorecards are high-level outcome metrics and as such are typically lagging indicators. A lagging indicator is a quality, safety, or financial sign that becomes apparent only after a large shift has taken place over time. Therefore, lagging indicators confirm long-term trends, but they do not predict them. In other words, improvements in the underlying BDA processes may be noticed more readily with the dashboard metrics, yet there may be a delay of weeks to months before they show up in the scorecard's “leading” metrics.

Training of the MH staff, clinicians and leadership (Appendix IX)

Ongoing learning about patients, customers, processes, ideas, and each other propels the lead improvement engine. The MH Surgical Improvement Training Program relied on lean tools and concepts and covered the major approaches to surgical safety and quality improvement. Program participants were taught to understand the advantages and disadvantages of various ways of organizing surgical services according to a range of tools, criteria, and approaches for improving cost, quality and service.

The consulting team designed a training program to help MH clinicians, healthcare risk management, and patient safety professionals understand and apply their key contributions to improve surgical patient care and outcomes. The consulting team collaborated closely with the Operations Performance Management Department (OPM) to deliver a consistent approach toward improving MH surgical services. The HR department learning management system (LMS) system facilitated access and oversight to the training materials. The consulting team designed the training with a “bias toward action” approach that was conducted “just in time” for MH and BDA teams to immediately apply the new system's knowledge and skills as they lead the BDA surgical improvement work.

Communications and messaging—internal and external

Vigorous daily and regular communications are essential for any surgical improvement program to succeed. The consulting team heard from front-line clinicians and senior executives about their deep and emotional commitment to care for their communities. The consulting team crafted the surgical improvement project to closely align with these bedrock values. The larger story of the project was aligned with the key messages of commitment to patient and community centered care, deep investment in the staff wellness and loyalty, lean/six sigma operations, and above all-being a good steward of community financial resources. These core messages need to be explained and articulated in the messaging. This transformation effort was complex and fast moving with multiple stakeholders and audiences. The consulting team identified several practices believed as success factors. The following steps were done.

• Hospital President public messaging to community-August 2020

  • “Over the years our surgical performance has not met the highest expectations of our patients, our medical staff, and industry best practices. That must end now!”

  • “We are launching a large, focused effort to redesign and change the culture of this organization.”

  • “We will focus on delivering:

    • ⁃

      Safest and high-quality outcomes

    • ⁃

      Improved efficiencies

    • ⁃

      Improved patient experience

    • ⁃

      Better caregiver and surgeon work environment”

  • “Muda Health and the current leadership is committed to making a difference to everyone we serve.”

• A dedicated intranet website was launched at the beginning of the transformation project:

  • serving as a repository for all facets of the SSI improvement project,

  • supporting the work effort by the LST/BDA/VST teams,

  • featuring the latest news, work products, photos, videos, and frequently asked questions.

• Learning Management System (LMS)—The consulting team developed training materials for the MH LMS for ease of access and learner follow-up and to support the training of all MH members in lean and HRO methods of improvement and reliable outcomes.

• Monthly workshops and seminars (see Appendix IX) were conducted throughout the project.

Massive variation with pre-operation clinics operations

Deep dive into surgical site infections (SSI)

We focused on SSI because they are preventable and result in devastating complications with significant morbidity after surgery ( Figs. 15.6–15.10 ). MH reported greater than 200 SSIs in 2020 with an estimated cost to the hospital of approximately $4.2 million. ⁸

8 National estimated SSI average cost: $20,785.

First, a champion was designated to represent their project to the SLT ( Fig. 15.25 ). The champion is the “rock removal” leader who sought to eliminate the barriers to success. With the support of the consultants, a deep dive into SSI identified SSI risk factors using evidence-based practices while applying a lean six sigma approach to problem solving.

We mapped the patient processes to help understand where the SSI might be originating from (before–during–after surgical processes) ( Fig. 15.26 ). The data collected included the patient-related factors, sterilization and the hygiene practices in the OR and OR flow and traffic, and compliance to the bundle of care. The gap analysis helped identify the potential risk factors.

Gap Analysis ( Fig. 15.27 ): A comprehensive gap analysis was completed that compared national best practices with the perioperative processes currently in place at MH in order to determine the “gaps” and help MH best focus on improvement efforts most at need at MH.

• Antibiotic Administration and Redosing Guidelines ( Table 15.1 ): Wide antibiotic fallout was noted by time of day and day of week with over 50% of patients not receiving full antibiotic coverage from midnight to 7 a.m. and over 40% did not get their required antibiotic on Saturday surgeries. Variation was found. A dosing and redosing guideline for prophylactic antimicrobials during surgery was agreed upon and a review of all antibiotic fallouts from clinical practice guidelines was done weekly.

  Table 15.1

  Effect of night surgery on antibiotic fallout- time of day.

  Time range of surgery case	Fallouts	Total	%Rate
  00:00–>07:00	2	4	50.00%
  07:00–>12:00	8	55	14.55%
  12:00–>17:00	5	40	12.50%
  17:00–>24:00	6	21	28.57%
  Total	21	120	17.50%
  Antibiotic fallout by day of the week
  Day of the week	Fallouts	Total	%Rate
  Sunday	1	10	10.00%
  Monday	4	32	12.50%
  Tuesday	8	23	34.78%
  Wednesday	2	23	8.70%
  Thursday	3	18	16.67%
  Friday	0	7	0.00%
  Saturday	3	7	42.86%
  Total	21	120	17.50%

• SSI Case Review/Investigation tool ( Fig. 15.27 ): A robust peer review template was developed with standardized definitions for SSI that provides reviewers (physicians and nurses) with a series of agreed on data points and pictures to help identify SSI risk factors and discussion questions to determine trends and opportunities for improvement related to SSI.

  

• SSI Team and Focused Subgroups ( Figs. 15.28–15.30 ): The data showed that colonic and small bowel surgery had the most variation and higher than standard infection (SIR) national rates. Multidisciplinary teams were dedicated to eliminating preventable SSIs, GI subgroup reviews data, and case reviews of SSIs were done weekly.

  
  
  

• Environmental Cleaning Process: Standardized process and checklists for OR cleaning prior to first case of the day, end of case, and terminal cleaning (end of day) were implemented. The consulting team facilitated a focus on quality with ATP testing as the quality metric.

• Surgeon Report Cards: The chair of surgery introduced surgeon report cards to include individual SSI rates and comparisons with MH peers, and this was agreed to by a majority vote of the surgeons.

• Patient Education: Patient education materials were created with the purpose of addressing what patients can do to prevent SSI and how to perform preoperative cleansing either through showers and skin wipes.

• Routine Audits: Scheduling and conducting of unannounced audits was implemented to document infection control in the perioperative service line with agreed to reporting back to surgeons, nurses, anesthesia, Cliically registered nurses anesthesists (CRNAs), and to the senior leadership team (SLT).

• Leadership SSI goals were crafted and reviewed regularily ( Fig. 15.31 , Fig. 15.32 ).