Process Improvements Lead to Surgical Site Infection Reduction and NSQIP Rating Excellence

In an effort to reduce the incidence of surgical site infections in the Division of Colon and Rectal Surgery at Mayo Clinic Rochester, a multidisciplinary team was formed. ME&C was engaged to help with data analysis, team facilitation, and implementation. The goal was to reduce the incidence of surgical site infections, and to improve this performance to the top decile in the National Surgical Quality Improvement Program (NSQIP).

The team’s experience was published in the Journal of the American College of Surgeons, and the team was an active participant in the Joint Commission Transformation of Care Collaborative on Reducing Surgical Site Infections. Read article

Check out our knowledge sharing webinar featuring Dr. Cima, Surgical Site Infection.

Surgical site infections have many causes, and many staff members interact with each and every patient that goes through surgery. The challenge was ensuring each patient gets the same pre-operative education and that staff utilized the same best practices.

To tackle this challenge, ME&C utilized process improvement methodologies to identify and test evidence-based strategies shown to have an impact on reducing surgical site infections. The multidisciplinary team that worked on this project developed strategies to reduce infections including: -Pre-operative strategies including a process to ensure adequate cleansing of the patient prior to the procedure -Intra-operative tactics including the appropriate use of prophylactic antibiotics and adequate cleansing of the sterile surgical field -Post-operative plans engaging the patient and staff in ensuring adequate care of the surgical wound

Through implementation of teams’ recommendations, several positive results occurred: -Surgical infections were reduced by 5.8% -Improved financial performance with a decrease in length of stay -Improved performance in the NSQIP program to top ten percentile.

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