Surgical site infection (SSI) is one reason that patients get readmitted within 30 days following the procedure. A quality improvement (QI) project will focus on prevention in order to lower the hospital’s SSI rate. The Plan-Do-Study-Act (PDSA) cycle is an appropriate framework to guide the QI process (Taylor et al., 2014). The “plan” phase entails forming a project team and should involve nurses, physicians, and other healthcare professionals who can impact the incidence of SSI. The team will perform a root cause analysis (RCA) to assess the contributory factors to the SSI and identify the goals and objectives of the QI project (Tjia et al., 2014). The RCA entails asking the question why SSIs occur and exploring hospital data to find the answers. For instance, a common root cause is poor staff compliance with prevention guidelines which recommend a multifaceted approach encompassing preoperative skin preparation, antibiotic prophylaxis, infection control measures, perioperative patient management, physical environment, and instrument sterilization (Bratzler et al., 2013). Once specific areas of poor compliance are identified, further analysis will determine why compliance is low and may be because of a lack of knowledge, absence of facility guidelines or lack of a culture of safety. Whichever the root causes, the QI project should be designed to address these (Tjia et al., 2014). The project components must be based on research evidence and requires searching and appraising the literature (Cima et al., 2013). The components will then be translated into facility guidelines, policies or protocols that will direct staff behaviors during the different stages of surgery.
Subsequently, the “do” phase pertains to piloting the project in a few units (Taylor et al., 2014). The “study” phase then involves an analysis of the outcomes of the pilot to determine if the interventions truly lead to SSI reduction. Small-scale implementation also reveals weaknesses in the plan prompting improvements in the project design prior to full implementation which is the “act” phase (Taylor et al., 2014). The saying goes that “you cannot change what you cannot measure.” This means that the baseline SSI rate must be measured and subsequent SSI cases recorded to enable serial calculations of the SSI rate for surveillance or monitoring (Cima et al., 2013). The weekly or monthly rates are then plotted on a run chart which will provide feedback to the team and the staff on the progress of QI (Cima et al., 2013). A consistent reduction in SSI rate from baseline proves that the QI project is effective. If not, the QI team must determine the barriers to achieving the project goal and troubleshoot.
It is important to emphasize that the success of the QI process relies on the commitment of direct care staff responsible for enacting SSI prevention. The QI team should then also focus on managing the change process (Levin et al., 2016). Education and training on SSI prevention, good communication, role-modeling by senior staff, coaching, encouragement, and recognition/rewards are some strategies to develop staff competency and attitudes favorable to putting evidence into practice through guideline adherence (Levin et al., 2016). Covert observation is a good, objective technique to measure adherence so that additional strategies can be undertaken to continually improve it and sustain the positive outcomes on SSI occurrence.
References
Bratzler, D.W., Dellinger, E.P., Olsen, K.M., Perl, T.M., Auwaerter, P.G., Weinstein, R.A. (2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy, 70(1), 195-283. doi: 10.2146/ajhp120568
Cima, R., Dankbar, E., Lovely, J., Pendlimari, R., Aronhalt, K., Quast, L. (2013). Colorectal surgery surgical site infection reduction program: A national surgical quality improvement program – driven multidisciplinary single-institution experience. Journal of the American College of Surgeons, 216(1), 23-33. doi: http://dx.doi.org/10.1016/j.jamcollsurg.2012.09.009
Levin, R.F., Wright, F., Pecoraro, K., & Kopec, W. (2016). Maintaining perioperative normothermia: Sustaining an evidence-based practice improvement project. AORN Journal, 103(2), pp. 213.e1-213.e13. doi:10.1016/j.aorn.2015.12.020
Taylor, M.J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J.E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality and Safety, 23, 290-298. doi:10.1136/bmjqs-2013- 001862
Tjia, I., Rampersad, S., Varughese, A., Heitmiller, E., Tyler, D.C., Uejima, T. (2014). Wake Up Safe and root cause analysis: Quality improvement in pediatric anesthesia. Anesthesia & Analgesia, 119(1), 122-136. doi: 10.1213/ANE.0000000000000266
