Reducing surgical site infections (SSIs) is a very real challenge—one that must be addressed to make health care more reliable and to improve patient safety. A new implementation guide published by The Joint Commission is designed to help health care organizations and health care professionals accomplish this goal by providing effective practices for implementing National Patient Safety Goal (NPSG) 07.05.01, which focuses on preventing SSIs. The practices were identified through a multi-phase process that included the participation of 17 Joint Commission-accredited hospitals and are now available in a guidebook titled The Joint Commission’s Implementation Guide for NPSG.07.05.01 on Surgical Site Infections: The SSI Change Project, which is available free of charge.
A national issue
Approximately 500,000 SSIs occur every year and contribute to increased length of stay, reduced quality of life, and death.*† Although evidence-based practices (EBP) to prevent SSIs have been well-described in the infection prevention and control literature, studies indicate that many hospitals have yet to adopt EBP to decrease SSIs.*†‡ In an effort to help health care organizations and professionals reduce the risk of SSIs, The Joint Commission established a NPSG that focuses exclusively on this public health concern. Even though NPSG.07.05.01 specifies the evidence-based requirements for preventing or reducing SSIs through eight elements of performance (EPs), accredited health care institutions have informed The Joint Commission’s leadership that guidance and direction are needed for successful implementation.
The Joint Commission’s SSI Change Project was launched in 2010 to focus on feedback from accredited organizations regarding NPSG.07.05.01. Specifically, The Joint Commission sought to learn, through an environmental assessment survey (EAS), effective implementation practices from currently accredited hospitals to successfully implement the SSI-focused NPSG (phase one of the SSI Change Project). The effective practices used to implement the SSI NPSG were confirmed through conference calls with select hospitals that participated in the EAS (see sidebar). The final result is the 2013 publication of a guide that offers accredited hospitals effective practices that may be used to implement NPSG.07.05.01.
Joint Commission implementation guide
A total of 17 Joint Commission-accredited hospitals, including three pediatric hospitals, participated in learning conference calls to confirm the effective practices identified in phase one of the SSI Change Project. Participating institutions are as follows:
- Baptist Hospital, Miami, FL
- Children’s National Medical Center, Washington, DC
- Hillcrest Hospital, Mayfield Heights, OH
- Lucile Packard Children’s Hospital at Stanford, Palo Alto, CA
- Mercy Hospital, Part of Allina Health, Coon Rapids, MN
- Methodist Willowbrook Hospital, Houston, TX
- Mobile Infirmary Medical Center, AL
- New York University Langone Medical Center, New York, NY
- Our Lady of Lourdes Regional Medical Center, Lafayette, LA
- Saint Mary’s Regional Medical Center, Russellville, AK
- Sinai Hospital of Baltimore, MD
- Sonora Regional Medical Center, CA
- St. Christopher’s Hospital for Children, Philadelphia, PA
- St. Tammany Parish Hospital, Covington, LA
- United Regional, Wichita Falls, TX
- University Medical Center, Lubbock, TX
- Vail Valley Medical Center, CO
The Joint Commission implementation guide defines 23 effective practices, includes supporting statements from participating hospitals, and offers a recommended method for using the guide. The effective practices are grouped into three major categories: effective practices for leadership, practitioner-focused effective practices, and effective practices for process improvement. The process category includes three subcategories: performance improvement-focused techniques, process improvement activities, and clinical interventions to decrease SSIs. A specific section focused on pediatrics is included, which comprises eight effective practices for this patient population.
An interesting finding of the SSI Change Project was that organizations that successfully implemented NPSG.07.05.01 and decreased SSIs did so by addressing the evidence-based elements of performance as a whole, rather than focusing on each of the NPSG’s elements of performance separately. Additionally, organizations focused implementation efforts on one type of surgical procedure rather than many operations simultaneously. Migration of evidence-based practices occurred when practitioners of one surgical area became knowledgeable of successful SSI reductions in another area and subsequently adopted the evidenced-based practices.
Implementing the effective practices
Organizations can use the effective practices identified for implementing NPSG.07.05.01 in a number of ways. Whether the effective practices are discussed at the leadership level, addressed at a surgical multidisciplinary team or quality meeting, or specific effective practices are selected for implementation when performing a specific surgical procedure, it is recommended that any institution considering a serious assessment of the effective practices conduct a gap analysis.
A one-page worksheet in the implementation guide provides a template for organizations to conduct the gap analysis. By conducting a formal gap analysis for NPSG.07.05.01, organizations can create a plan, based on organizational priorities, for implementing all or a subset of the 23 defined effective practices. The multidisciplinary team involved in the surgical procedure should work together to conduct the gap analysis. All members need to be familiar with the effective practices for implementing NPSG.07.05.01 and their definitions. The team should also include a member of leadership who is responsible for resource allocation. With the gap analysis complete and with leadership support, the multidisciplinary team has a road map for implementing the effective practices associated with NPSG.07.05.01.
To download The Joint Commission’s Implementation Guide for NPSG.07.05.01 on Surgical Site Infections: The SSI Change Project, visit The Joint Commission website.
*Meeks DW, Lally KP, Carrick MM, Lew DF, Thomas EJ, Doyle PD, Kao LS. Compliance with guidelines to prevent surgical site infections: As simple as 1-2-3? Am J Surg. 2011;201(1):76-83.
†Anthony T, Murray BW, Sum-Ping JT, Lenkovsky F, Vornik VD, Parker BJ, McFarlin JE, Hartless K, Huerta S. Evaluating an evidence-based bundle for preventing surgical site infection: A randomized trial. Arch Surg. 2011;146(3):263-269.
‡Yokoe D, Mermel LA, Anderson DJ, Arias KM, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E, Marschall J, Nicolle L, Pegues DA, Perl TM, Podgorny K, Saint S, Salgado CD, Weinstein RA, Wise R, Classen D. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29 Suppl 1:S3.