1. Together, our Promise is YOUR HEALTH.
Lakeland Regional Health (LRH) is committed to
continuous improvement and a multi-phase process
improvement effort to reduce Surgical Site Infections
was initiated in October 2013. The goal of the project
is to reduce and sustain near zero surgical site
infections . As a result, standardized improvement
efforts were implemented across the preoperative,
intraoperative, and postoperative phases of care.
OBJECTIVES
Lakeland Regional Health is a full service medical center and health system. As an 851 bed, not for
profit medical center, Lakeland Regional Health (LRH) is the fifth largest hospital in the state of Florida
and also operates the busiest single-site Emergency Department in the state. LRH has an average
surgical case volume of over 1400 cases per month.
REDUCING SURGICAL SITE INFECTIONS:
A standardized and evidence-based approach
A multi-phase process improvement effort was
initiated in October 2013. The project team consisted
of executive, physician, quality, surgical services,
industrial engineering, information technology, and
infection prevention leadership. The project team
completed a three month gap analysis and utilized
evidence based research, workflow analyses, data
analyses, and root cause analyses to determine a set of
standards to reduce surgical site infections.
RESULTS & IMPLICATIONS
KEYS TO SUCCESS
Sheena M. Butts, CSSBB, Industrial Engineer
DESIGN
PARTICIPANTS
SMART LEAN: Practicing Thoughtful Activity & Execution of Accountability
PURPOSE SETTING METHOD
• Reduce and sustain near zero surgical
site infections
• Improve patient experience
• Implement standard evidence-based
clinical pathways through the
preoperative, intraoperative, and
postoperative phases
Our results indicate that we have reduced our surgical site
infection rate. This successful projects demonstrates that
changes can be made across the health system to
standardize and implement evidence-based processes for
all providers in order to decrease surgical site infections.
Of note, the team completed a statistical analysis of our 3M Nose to Toes trial for MRSA
decolonization and determined to discontinue use as the evidence for efficacy was not evident
after a 6 month trial period.
 Executive Leadership Support
 DYAD collaboration between surgical services leadership
and physician leadership
 Technology and System Improvements
 Industrial Engineering Principles
 SMART LEAN Methodology
 Standard Work
The preoperative standardizations include; a uniform shower
chlorohexidine sequence, standardized pre and post-operative
instructions, standardized clipping protocol (outside the operating room
for qualifying cases), trial of 3M SAGE Noes to Toes kit for Total Hip and
Total Knee cases, electronic MRSA alert, revised prophylactic antibiotic
ordering and administration protocols, and nursing and physician
document changes to reflect standardizations. Intraoperative
standardizations include; CHG prep, automated operating room
temperature and humidity monitoring, appropriate wound classification,
revised surgical scrub attire policy, antibiotic re-dosing alert, positive
patient and medication identification, and standard room cleaning and
monitoring. The post-operative standardizations include; post-operative
antibiotic administration alert, Surgical Site Infection letter provided to
surgeons, and an automated follow-up phone call.
Timothy Regan, MD, COQ; Graham F. Greene, MD,CAO,
FACS,FRCP; Margie Voyles, RN, MS; Carrie Ogilvie, RN, MSN;
Jewels Stark, RN, BSN, MS, MBA; Michelle Hunt, BSMT, ASCP,
CIC; Pam Troxell, RN, MSN, CNOR, CIC; Mary Beth Perry, RN,
MSN CPAN; Cateria Davis, RN, BSN; Cheryle Smith, RN, MSN;
Diane Campbell, RN, MSN, CSSBB; Wanda McManus, RN, BSN,
CPHQ, CPPS; Belinda Freer, RN; Jessica Cobian, PharmD,
BCPS; Ever Glendenning, RN, BSN,CPAN; Derek Cyr, CPHIMS;
Sheena Butts, IE, CSSBB
Preoperative Phase Intraoperative Phase Postoperative Phase
• Washing Kits and Patient Shower sequence with Hibiclens
(CHG)
• Standardized Pre & Post Operative Instructions
• Clipping Process to be completed outside of OR for qualifying
cases
• MRSA Alert
• Trial of Total Hip and Knee Surgeries with 3M Noes to Toes
Kits
• Prophylactic Antibiotics ordering and workflow redesign to
ensure appropriate antibiotic choice, dose, and timing
• Nursing and Physician documentation changed to reflect and
track process changes
• CHG prep
• OR room temperature and humidity levels monitored with
TempTrack
• Antibiotic Re-dosing Alert
• Positive Patient Identification Protocol & Positive Medication
Identification (PPID & PMID)
• Surgical Scrub Attire Policy
• Appropriate Wound Classification
• Standard OR room cleaning process (including 3M Clean
Trace monitoring)
• Postoperative Prophylactic Antibiotic Administration Alert (1
hour prior)
• Automated Follow-up phone call
• Surgical Site Infection (SSI) letter to surgeon
Sample: Standardized Clipping Instructions
2.5
1.94
2.14
2.26
1.84
1.22
1.11
1.63
1.83
1.1
0.89
0
0.5
1
1.5
2
2.5
3
Oct 2014 Nov 2014Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015May 2015Jun 2015 Jul 2015 Aug 2015
NHSN SSI Rate