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5 must-haves for effective quality improvement

Publish Date: 2/13/2013

Shirin Towfigh, MD, FACS, and surgical colleagues at Cedars-Sinai Medical Center in Los Angeles have found success with implementing effective quality improvement, and they have the data to prove it:

The rate of postoperative surgical site infections after colorectal surgeries dropped from a baseline of 15% to less than 5% within six months following the implementation of an evidence-based SSI bundle.

This colorectal SSI quality improvement initiative started in August 2010 as part of a broader colorectal SSI project led by the Joint Commission Center for Transforming Healthcare in collaboration with American College of Surgeons. The Joint Commission Center for Transforming Healthcare partners with health care organizations that use a systematic approach to analyze specific breakdowns in patient care and discover underlying causes to develop targeted solutions that solve these complex problems.

For this SSI project, Cedars-Sinai Medical Center joined six other participating hospitals in applying Robust Process ImprovementTM methodology to design their evidence-based SSI bundle targeted to their organization’s unique list of contributing factors to colorectal SSIs.

Under Towfigh’s project leadership at Cedars-Sinai Medical Center, her QI team measured the incidence of colorectal SSIs, identified contributing factors for these infections, established a low-cost SSI prevention bundle and worked as a multidisciplinary group to successfully implement the bundle across all surgical settings.

Towfigh, an attending surgeon and director of Cedar-Sinai’s medical student education program, says her facility’s sustained reduction of SSIs through this project highlights the power of QI data—when data are collected and used correctly.

“Clean data is key, but what’s more important is how you communicate the data to empower everyone who has a stake in safe patient care,” Towfigh says. “We continue to find success in widespread use of our SSI bundle by showing surgical team members what the evidence indicates is the right thing to do; this gives them the knowledge to choose these safety practices as their default action.”

Here are Towfigh’s must-have elements for effective quality improvement to address today’s health care challenges:

1.Build a smart QI team (don’t forget perioperative nurses!)
The QI team for this SSI project involved a diverse group of representatives from across the hospital, including surgical team members, hospital epidemiologists and QI specialists who were supported to dedicate their time to the project. “Leadership buy-in is key for any QI project,” Towfigh stresses. She also says perioperative nursing is key for any QI project that involves changes in surgical practice. “Our perioperative nurses acted fast to implement the needed elements for the colorectal SSI bundle; without our perioperative nurses, this project would not have been successful.”

Towfigh also stresses the importance of naming a QI project leader who commands respect and serves as the face of the project.

2. Ask, don’t bully when requesting QI practice changes
Getting widespread buy-in is always a challenge with any QI project, Towfigh acknowledges. “I knew from the beginning that I would have to present this project to the surgeons in a flexible way. I asked them to consider making these changes, and in turn I would give them actionable patient data—this helped surgeons understand the tangible value of testing the SSI bundle.”

3. Keep QI changes simple, and explain the science behind changes
Our bundle is simple—we didn’t buy expensive dressings or new technologies to implement changes, instead we used what we had and limited our changes to what we knew could be easily implemented, Towfigh explains. “We also focused a lot of time on open dialogue to share the scientific rationale for our changes. Explaining the evidence behind QI decisions will get much more buy-in.”

4.Collect clean QI data, and know how to talk about findings
Educate team members who are working directly with the QI project so everyone understands how to correctly collect and implement accurate QI data, Towfigh advises.

QI data should be presented in a way that is clear and not overwhelming, or the power of the data will be lost, she notes. “Surgeons are visual, if you are going to be successful in having them change their practices, they need to see the evidence in a clear, accurate way.”

5. Bring QI back to the patient
“Focus on meaning, not memorization when implementing QI changes,” Towfigh stresses. With the continued use of their SSI bundle, questions still come up and she explains the evidence-based rationale for the QI changes in simple terms, focusing on how the action protects the patient.

“Our common goal to provide the highest level of care for our patients never changes, but new practices and new evidence change the way we provide this high-level care,” Towfigh says. “Disseminating education on these changes in a respectful, convincing way is the cornerstone of successful quality improvement.”

Additional Resources

Learn about the evidence-based protocols used to reduce colorectal SSI infections at Cedars-Sinai Medical Center.

Find strategies for engaging nurses in quality improvement activities.

Explore the Joint Commission Center for Transforming Healthcare website to learn about the colorectal SSI project and other projects where the Center has worked with leading health care organizations in applying Robust Process ImprovementTM methodology. These projects include hand hygiene, hand-off communications, safety culture, wrong-site surgery, and more.

Guidelines for Perioperative Practice


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