ACS NSQIP National Conference inspires participants to innovate to make a difference

The pursuit of quality improvement (QI) is what drives surgeons and other health care professionals to attend the American College of Surgeons Annual Surgical Quality Improvement  Program (ACS NSQIP^®) conference, said Clifford Y. Ko, MD, MS, MSHS, FACS, Director, ACS NSQIP and ACS Division of Research and Optimal Patient Care, in his welcoming remarks at the 11th annual ACS NSQIP Annual Conference. The theme of this year’s conference, July 16−19 at the San Diego Bayfront Hilton, CA, was Innovate to Make a Difference.

“Everybody wants to innovate, but few want to change,” Dr. Ko told the gathering of nearly 1,500 surgeon champions (SCs), surgical clinical reviewers (SCRs), and other QI leaders.

“What we’re fighting is the attitude that, ‘We’ve always done it this way.’ Our goal is to find better ways to do things and to make changes in the way we approach standards of care,” he said. Comparing the QI task to moving an immense boulder, Dr. Ko said, “Every day, we’re working to move that boulder uphill.”

Dr. Ko said that New York Times blogger Pauline Chen, MD, FACS, got it right years ago when she called ACS NSQIP “a better way to keep patients safe.” Speakers throughout the conference described steps they take to ensure patient safety. The conference offered a variety of sessions aimed at reducing surgical complications, applying QI concepts to difficult surgical problems, and maximizing efficiency and resource use in health care. Many sessions also offered strategies for adapting to a changing health care environment and using evidence-based tools and case studies to improve organizational culture.

This year’s meeting was co-chaired by E. Patchen Dellinger, MD, FACS, professor and vice-chairman, and chief, division of general surgery, University of Washington Medical Center, Seattle; and Molly Clopp, RN, MS, strategic leader, patient safety, Kaiser Permanente, San Francisco, CA.

Keynote address: Resilience

Surgery is all-consuming—from training to practice—but it also can be highly rewarding, said Julie A. Freischlag, MD, FACS, Past-Chair, ACS Board of Regents, in her keynote address, Career Satisfaction by Way of Resilience. An academic health care leader, Dr. Freischlag oversees the University of California (UC) Davis Health System’s academic, research, and clinical programs, including the School of Medicine, the Betty Irene Moore School of Nursing, the 1,000-member physician practice group, and UC Davis Medical Center.

“Surgeons fret and we worry because we care,” Dr. Freischlag said. “Despite our best efforts, someone’s going to return to the hospital, and as a surgeon, you need to generate ways to bounce up.” Lack of resilience often leads to burnout, which manifests itself as anxiety, depression, broken marriages/relationships, alcoholism, substance abuse, and suicide. “Surgeons have to learn how to reboot, so they don’t drive the people around them crazy,” she said.

She offered suggestions for avoiding burnout, including staying connected to other people. “When things are not going well, take the time to see a friend,” she said. “People are what will get you through the toughest times.” Find mentors and be a mentor, she advised. Be a good colleague, and try to help your colleagues who are experiencing burnout. “Do not hesitate to have those difficult conversations,” Dr. Freischlag said.

Dr. Freischlag noted that the health care paradigm has changed, with patients driving quality improvement, and surgeons need to be resilient in response to these changes, as well.

“As surgeons, we’ve got to move forward,” she said. Earlier in her career, when she worked for the Veterans Health Administration (VHA), Dr. Freischlag recalls that members of the operating room (OR) team worried that if they reported their complications they would create problems for the VHA and their colleagues. Today, reporting problems and understanding why they occur are considered part of the solution.

ACS NSQIP is based on the premise that members of the surgical team can learn from their mistakes—that they can be in a state of continuous quality improvement. According to Dr. Freischlag, surgeons should be judged not by their mistakes, but by their resilience—how well they recover from an error. “I don’t measure success by how high a surgeon climbs, but how that surgeon bounces back from rock bottom,” Dr. Freischlag said.

Culture trumps everything, Dr. Freischlag added. “You have to understand your culture in order to change it,” she said. “Learn to be resilient. When they tell you that you can’t, tell them that you can, and make sure you’re right.”

Town Hall

New at this year’s conference was a Town Hall with ACS Executive Director David B. Hoyt, MD, FACS, moderated by Bruce L. Hall, MD, PhD, MBA, FACS, professor of surgery, Washington University; vice-president of quality, Barnes Jewish Hospital, St. Louis, MO; and ACS NSQIP Consulting Director. Dr. Hoyt reviewed legislative and regulatory issues affecting surgery and the role of ACS Quality Programs in influencing these initiatives and their implementation.

A key factor driving health care reform in the U.S. is cost, according to Dr. Hoyt. “The cost of health care has woken us up,” he said, and there is pressure to lower it. Many of the legislative and regulatory responses to rising health care spending have focused on physician payment reform.

Most recently, the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015 established a new Quality Payment Program (QPP). Physicians have two pathways to participation in the QPP: the Merit-based Incentive Payment System (MIPS) or advanced Alternative Payment Models (APMs). (See related story, page 20 of this issue.) Surgeons who put the patient at the center of care should do well under MACRA, Dr. Hoyt said.

Surgeons are well-positioned to lead QPP implementation, as they have been leading the charge toward patient-centered, evidence-based care for more than a century. “Surgeons have been the most aggressive among health care professionals in engaging quality improvement,” Dr. Hoyt said. “We now have to be accountable to our patients, and surgeons are as ready as anyone for this challenge.”

Performance is going to be measured, and without valid, robust data that flow from QI initiatives, hospitals cannot accurately compare their performance with other hospitals or between patients. “We’ve got to create the intellectual trust, because if we do, important people will follow,” Dr. Hoyt said.

Other ACS quality-related activities that Dr. Hoyt discussed included the development and release of statements on perioperative care and OR attire; efforts to ensure that general surgery residents are adequately prepared for surgical practice when they finish training, including the ACS Transition to Practice program; and the changing surgical culture.

“I think it’s an exciting time to be a surgeon,” Dr. Hoyt said. “We’ve got to change the culture, and we’ve got to have the right tools.”

Managing change

In a preconference session, SCs, SCRs, and other attendees reviewed a case study involving a hospital that had received an ACS NSQIP report showing that its surgical site infection (SSI) rates were increasing. Session participants determined that this problem could be attributed to a range of factors, including miscommunication during patient handoffs, conflicts between the surgical staff and the circulating nurses, administrative pressures to cut costs, a shortage of intensive care beds, and changes in leadership in anesthesiology. The group determined that many of these issues would remain unresolved without a change in the institutional culture.

“Leading and managing change is a lot harder than it looks,” according to session moderator Nestor F. Esnaola, MD, MPH, MBA. Surgical leaders must guide the change management process, said Dr. Esnaola, associate director, cancer health disparities and community engagement; attending surgeon, gastrointestinal oncology, hepatopancreaticobiliary surgery; and sarcoma professor, department of surgical oncology, Fox Chase Cancer Center, Temple University, Philadelphia, PA.

“Change is not an event,” he said. It’s a planned and structured process, and it only can occur when change champions get buy-in across the department and institution, preferably from people who are in high-power/high-influence positions initially.

To motivate health care professionals to accept change, you have to “shock them out of the status quo.” Show them high-quality data that point to a real problem, Dr. Esnaola said. Communicate a vision and strategy for change, and empower broad-based action. Start with small improvements that people can see and appreciate. Then, explain the gains to drive more change, and hardwire the changes into the culture.

Surgeon champions

In a breakout session for new SCs, Charles A. Lane, MD, FACS, a general and laparoscopic surgeon, Maryville, IL, urged SCs not to “criticize, condemn, or complain. The challenge is to engage and influence your colleagues,” he said. “You will become the face of [your institution’s] quality improvement program, and they’ll be counting on you to be the change agent.” He advised: Take the softer approach. Always ask them to consider something. Don’t show anger or frustration. Good opening phrases include “Tell me more about it,” and “What are your thoughts?” Show humility, he said. Listen more, and talk less.

Pierre F. Saldinger, MD, FACS, chairman, department of surgery, surgeon-in-chief, New York-Presbyterian, Queens, discussed local organizational culture. “Culture is what people do when no one is looking,” he said. A cynical attitude toward change and a lack of faith in the organization’s ability to transform itself are examples of barriers to change.

In another session for SCs, Robert E. Glasgow, MD, FACS, professor of surgery, University of Utah School of Medicine; section chief, gastrointestinal and general surgery, division of general surgery; and vice-chairman, clinical operations and quality and chief value officer, department of surgery, University of Utah, Salt Lake City, emphasized the importance of actively using ACS NSQIP reports to drive change. Allan Siperstein, MD, chair of endocrine surgery; program director, general surgery residency program and endocrine surgery fellowship; and SC, Cleveland Clinic, OH, noted that his institution sought to reduce SSIs. They succeeded in this effort by implementing standardized steps in the OR.

Joseph B. Cofer, MD, FACS, professor of surgery and surgery residency program director at the University of Tennessee College of Medicine, Chattanooga, has been involved in ACS NSQIP and an SC for 11 years. To be an effective SC, he said, “You have to be passionate about surgery and surgical outcomes, and you have to be willing to try to change the culture [in your institution].”

SCs also need to have some standing within the institution and have demonstrable leadership skills, Dr. Cofer said. They need to be magnanimous and effective communicators, and they need the support of an effective infrastructure.

Collaboratives must collaborate

Many successful ACS NSQIP participants are part of collaboratives. Karl Y. Bilimoria, MD, FACS, led a pre-conference workshop on the growing number of ACS NSQIP collaboratives. Dr. Bilimoria is a surgical oncologist and director, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, IL. Participants gathered at roundtables and provided overviews of their collaboratives, sharing stories about their successes and challenges.

Buy-in from the collaborative’s institutional leadership will largely determine the group’s success, said Olakunle Ajayi, MD, a colon-rectal surgeon, Kaiser Permanente, Oakland, CA. “The leaders are very interested in the return on their investment, so I keep them continually informed about how much money we’ve saved the hospital over time.”

Learning from mistakes

Panelists at a general session described what they learned from projects that did not go according to plan.

Saulat S. Sheikh, MB, BS, general surgery resident, York Hospital, PA, noted that SSIs account for approximately $8.6 billion in health care spending, according to a report from The Joint Commission Center for Transforming Health Care.* The goal at York Hospital was to bring the colorectal infection rate in line with the national average. The hospital implemented an SSI prevention bundle and monitored the change in SSI rate. After initial success, the hospital witnessed a substantial jump in SSIs. According to Dr. Sheikh, the lessons learned are that success does not always occur continuously, and failure can lead SCs to ask the right questions. All stakeholders must be involved, and a clear implementation plan and measures for compliance must be in place, he added.

Other speakers included the following:

• Elizabeth C. Wick, MD, FACS, a colorectal surgeon and assistant professor of surgery, Johns Hopkins University Medicine, Baltimore, MD, who discussed readmissions after complex abdominal operations
• Jyotirmay Sharma, MD, FACS, director, thyroid and endocrine surgery, Emory University Hospital; associate professor of general and endocrine surgery, division of general and gastrointestinal surgery, department of surgery, Emory University School of Medicine; and SC, Emory University Hospital, Atlanta, GA, who discussed his institution’s efforts to prevent hypothermia during complex procedures
• Ryan D. Macht, MD, a general surgery resident at Boston University Medical Center, MA, who spoke on patterns of failure identified in a standardized venous thromboembolism prophylaxis protocol

ERAS

Efren E. Rosas, MD, assistant physician-in-chief, hospital operations and OR, Kaiser Permanente San Jose Medical Center, CA, and Paul Preston, MD, anesthesiologist, Kaiser Permanente, San Jose, offered a view of enhanced recovery after surgery (ERAS) programs at Kaiser.

The Kaiser team promoted the ERAS tagline, “Get up, get moving, get better,” and developed a detailed plan for each patient, including specific pre- and postoperative instructions for pain control, diet, exercise, and other factors that affect recovery. Kaiser targeted colorectal and hip fracture patients for the ERAS program and used ACS NSQIP data to evaluate outcomes. The protocol included preoperative counseling, nutritional guidance, and administration of prescription painkillers. Kaiser found that ERAS reduced the length of stay for patients with hip fractures by 39 percent and for colorectal patients by 19 percent. Patient care improved based on multiple metrics, including pain management; occurrence of transfusion, urinary tract infection, and venous thromboembolism; and patient satisfaction.

Vanita Ahuja, MD, FACS, WellSpan York Hospital, PA, spoke on barriers to implementing ERAS in small and community hospitals. Rural and small hospitals serve approximately 23 percent of the U.S. population, and 20 percent of their patient population is age 65 and older, Dr. Ahuja said. The challenges of providing quality care to these patients include remote location, which can make it difficult to recruit skilled staff; surgeons with less experience than their counterparts in larger hospitals because of the low volume of certain procedures done; and distance to tertiary centers.

Improving pediatric and geriatric surgical care

The ACS has developed two programs to address the unique needs of pediatric surgical patients: the Children’s Surgery Verification^™ (CSV) Quality Improvement Program and ACS NSQIP Pediatric.

Keith T. Oldham, MD, FACS, professor and chief, division of pediatric surgery, Medical College of Wisconsin, Milwaukee, and Chair, CSV program, noted that pediatric surgery patients require different resources than their adult counterparts. However, “even today, a large segment of children receive care in nonspecialized environments,”

Dr. Oldham said. These general hospitals often lack the proper instrumentation and specialists needed to provide effective pediatric care. The CSV program seeks to ensure that all hospitals are equipped to address the needs of pediatric patients and that “every child in need of surgical care in North America today will receive care in an optimal environment,” Dr. Oldham said.

That vision culminated earlier this year with the release of Optimal Resources for Children’s Surgical Care—the nation’s first and only multispecialty standards for children’s surgical care. The ACS developed the standards with the Task Force for Children’s Surgical Care with an eye toward ensuring hospitals follow the College’s four guiding principles of QI—set the standards; build the right infrastructure; use the right data; and don’t trust, verify.

Diana L. Farmer, MD, FACS, FRCS, pediatric surgeon and chair, department of surgery, UC Davis, and a member of the ACS Board of Governors Executive Committee, said her institution served as a pilot site for the CSV program. Participation in the pilot created early quality benefits for pediatric patients at UC Davis, including enhanced efficiency, safety, and performance, she said. Specific changes included implementation of standards defining who can operate on children without the supervision of a pediatric specialist, adverse event analysis, and increased pediatric on-call care.

These changes happened through the work and guidance of a multidisciplinary children’s surgical performance and patient safety committee, Dr. Farmer said, allowing multiple departments and key personnel within the hospital at-large to collaborate, which was paramount to the program’s success.

Similarly, Texas Children’s Hospital, Houston, another pilot site, established a multidisciplinary surgical quality committee (SQC), according to director of strategic projects Laura Higgins, Esq. The SQC provides the infrastructure necessary to support QI initiatives, Ms. Higgins said. It has helped to improve accountability, prevent duplication of efforts, and ensure availability of optimal resources.

Jacqueline M. Saito, MD, FACS, assistant professor of surgery, division of pediatric surgery, Washington University School of Medicine, and a pediatric surgeon at St. Louis Children’s Hospital, MO, described how that institution used ACS NSQIP Pediatric data reports as a “prompt for a deeper dive” into adverse outcomes. This in-depth analysis was carried out through a multidisciplinary performance improvement and patient safety (PIPS) program. The PIPS group reviewed surgical deaths, complications, and other adverse events and compared quality performance metrics to national benchmarks. These findings were used to address outliers.

In addition, R. Lawrence Moss, MD, FACS, surgeon-in-chief, Nationwide Children’s Hospital, Columbus, OH, spoke on the importance of rare patient safety events as a measure of performance. In fact, analysis of such events led to the development of a Wake Up Safe anesthesia program.

Several sessions examined geriatric surgery. Thomas N. Robinson, MD, FACS, a member of the ACS Task Force on Geriatric Surgery and associate professor of surgery, University of Colorado, Aurora, and Ronnie A. Rosenthal, MD, FACS, Chair, Task Force on Geriatric Surgery, and professor of surgery, Yale University School of Medicine, New Haven, CT, led a session on Elderly Surgery and Outcomes. The session examined gauging patient frailty and other signs of readiness for surgery.

“Despite recent improvements in surgical technique, patient selection, and perioperative care pathways, 25 percent to 40 percent of patients undergoing liver resection develop a postoperative complication,” partly because they are too frail to withstand the procedure and recovery, said Timothy M. Pawlik, MD, MPH, PhD, FACS, a colon and rectal surgeon, Johns Hopkins University School of Medicine. Dr. Pawlik and his colleagues at Hopkins developed a frailty index based on routine preoperative clinical characteristics to predict postoperative complications and postoperative mortality following liver surgery.

Blair C. Baldwin, DO, a general surgery resident at Berkshire Medical Center, Pittsfield, MA, and colleagues sought to determine whether inguinal hernia repair can be performed effectively in elderly patients. Their research shows that surgeons should offer elective inguinal hernia repair to their elderly patients, although they endorsed further study of whether watchful waiting or elective surgery is more effective in patients ages 80 and older.

Jennifer Dwyer, MD, Nebraska Medical Center, Omaha, reported on a study designed to determine whether the risk analysis index score—a measure of frailty—correlates with complications after urologic operations. The study indicated that frailty affects both primary (mortality and pulmonary, cardiac, and infectious complications) and secondary (length of stay, readmission, return to the OR, discharge destination) outcomes.

Luis A. de la Cruz, MD, MBA, Baptist Hospital of Miami, described how a strategy combining risk stratification, protective intraoperative interventions, and postoperative renal function monitoring significantly reduced the incidence of acute renal failure in noncardiac surgery patients.

Beth Turrentine, PhD, RN, trauma care coordinator, acute care nurse practitioner instructor, University of Virginia, Charlottesville, offered insights into a study that tested the hypothesis that sarcopenia, as measured by preoperative computed tomography scans, predicts morbidity and mortality in emergent laparotomy.

Jonathan S. Abelson, MD, a general surgery resident at New York Presbyterian Hospital, New York, described a study of his institution’s use of the ACS NSQIP Surgical Risk Calculator in weekly morbidity and mortality conferences. The study showed that the risk calculator can be particularly effective in predicting patients with “above average” risk of complications.

Julia Berian, MD, an ACS Clinical Scholar in Residence who has played a significant role in the ACS and the John A. Hartford-supported Coalition for Quality in Geriatric Surgery, also spoke, offering insights into future directions in this growing surgical arena.

ACS Strong for Surgery

To ensure that all patients are in optimal condition for operative care, the College will be leading a national ACS Strong for Surgery initiative. Each year, approximately 210,000 preventable deaths occur in U.S. hospitals—half during some phase of surgical care, according to Thomas K. Varghese, Jr., MD, MS, FACS, head, general thoracic surgery, University of Utah; associate professor, department of surgery, University of Utah School of Medicine; and co-director, Huntsman Cancer Institute’s thoracic oncology program, Salt Lake City. According to Dr. Varghese, under the ACS Strong for Surgery model, health care providers use a series of checklists and tools first developed at the University of Washington, Seattle, in four modifiable areas to ensure the patient’s optimal readiness for operative care: nutrition, blood sugar, smoking status, and medication use.

Surgical ethics

Peter Angelos, MD, PhD, FACS, Linda Kohler Anderson Professor of Surgery, chief, endocrine surgery, and associate director, MacLean Center for Clinical Medical Ethics, University of Chicago Medicine, explored the concept of professionalism. Surgical professional ethics centers on three factors: the surgeon-patient relationship, the invasive nature of surgery, and informed consent for surgery. “What makes surgery unique is that it requires harm in order to heal,” Dr. Angelos said. “Healing cannot occur without actions that would be illegal in any other context. It is an intensely physical relationship.”

Informed consent in surgery allows patients to actively participate in the medical decision-making process and is rooted in respect for patient autonomy, Dr. Angelos said. Informed consent involves more than ticking off the risks, benefits, and alternatives to the patient; it also involves building trust. “Good data are essential for informed consent, but that is not enough,” Dr. Angelos said. “People don’t want to be operated on by people who can’t talk to them. The responsibility of surgeons goes beyond what happens in the OR.” It is the surgeon’s job to educate the patient about the condition, to clarify the goals of the operation, and to ensure that the patient is aware of risks, he added.

Personal perspectives

Several presenters at this year’s conference focused on personal stories, which they offered in a more conversational style. Thomas A. Aloia, MD, FACS, asked, “Should zero [errors] be the goal?” According to Dr. Aloia, SC and associate professor of surgical oncology, division of surgery, University of Texas MD Anderson Cancer Center, Houston, perfection is not a workable concept in surgery. If it were, high-risk patients would never receive surgical care.

“The surgeon has to balance issues of safety and quality,” he said. Safety has to do with the absence of harm to the patient, whereas quality has to do with efficient, effective, purposeful care that gets the job done at the right time for the right cost. Safety focuses on avoiding bad events. Quality focuses on doing things well. “Safety can drain a provider’s morale, but quality builds provider morale,” he said. “That’s why enhanced recovery has taken off.”

Kimberly McKinley, BSN, RN, quality leader, BC [British Columbia] Patient Safety and Quality Council, Penticton, BC, spoke about physician-patient communication. “We’ve all heard the expression, ‘It’s not what you say—it’s how you say it,’” she said. “But I truly believe that what we say matters. Nothing can override the power of a few poorly chosen words. Think of the power of your language, and take ownership of it.”

Rachel R. Kelz, MD, MSCE, FACS, an endocrine and oncologic surgeon and associate program director of the general surgery residency program, University of Pennsylvania, Philadelphia, spoke on the privilege of being a surgeon and of forming relationships with patients when they often are at their most vulnerable. Dr. Kelz noted that she has the privilege of being able to reassure them that they will be okay, and that they are not alone.

“All of us in this room have the potential to lead extraordinary lives,” Dr. Kelz said. By providing compassionate, quality care to surgical patients, she said, “we have the opportunity to extend our lives. We have the opportunity to be extraordinary.”

Offering advice for the modern surgeon was Oscar D. Guillamondegui, MD, MPH, FACS, professor of surgery medical director, trauma intensive care unit; director, Vanderbilt Multidisciplinary Traumatic Brain Injury Clinic; and vice-chairman, surgical quality, safety, and professionalism, Vanderbilt University School of Medicine, Nashville, TN. “Surgeons graduate from the school of anxiety,” Dr. Guillamondegui said, pointing to the high rates of depression and suicide among surgeons. “Stop comparing yourself to other surgeons. We’re all good, but learn from your mistakes,” he said. Vulnerability is what allows surgeons to do that.

Residents as leaders

The conference closed with a session aimed at the future of surgical innovation—surgical residents—which Dr. Kelz moderated. In this session, young surgeons described how their roles in other arenas have prepared them for surgical leadership.

John F. Sweeney, MD, FACS, chair, department of surgery, Emory University, described the lessons he learned as a high school and collegiate football player as follows:

• Culture begins at the top.
• Know and understand the legacy of your organization; an institution’s legacy informs its culture.
• If you prepare and work hard, opportunity will present itself.
• Celebrate success, but don’t get cocky.
• Be confident in your abilities and be optimistic about the outcome.

Importantly, “Don’t be concerned who scores the touchdown,” he added. “Just score the touchdown.”

Lillian Kao, MD, FACS, professor, department of surgery, division of acute care surgery, Lyndon Baines Johnson General Hospital and Clinic, University of Texas, Houston, explained what she learned about “cultivating culture” as president of the Association for Academic Surgery:

• Diagnose the current state of the team culture.
• Discuss results and brainstorm for possible improvements.
• Create a staff compact.
• Create opportunities for interaction.
• Meet regularly.
• Strengthen the team by focusing on individual development.
• Get to know team members.
• Teach leaders to be mentors, not just managers.
• Create an environment that encourages learning.
• Find a way to foster new membership.

Joseph V. Sakran, MD, MPH, MPA, FACS, who at the time of the conference was associate professor of surgery, division of general surgery, Medical University of South Carolina, Charleston, said his experience as a firefighter taught him the importance of camaraderie. Dr. Sakran defines organizational culture as “civilization in the workplace.” Each organization’s culture is unique. “Anyone can copy a company’s strategies, but you can’t copy its culture,” he said.

Dr. Sakran outlined the following core concepts that he promotes in his organization:

• Engage your patients.
• Communicate effectively and “listen with intent to understand.”
• Encourage camaraderie building by having team huddles and debriefings and spending time with the team outside of the OR.
• Move away from management structures.
• Demonstrate humility.
• Coach with clarity.
• Provide flexibility.
• Offer real-time feedback.

The next ACS NSQIP Annual Conference will take place July 21–24, in New York, NY.

---

*Joint Commission Center for Transforming Health Care. Reducing Colorectal Surgical Site Infections December 2014. Available at: www.centerfortransforminghealthcare.org/assets/4/6/SSI_storyboard.pdf. Accessed July 27, 2016.