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    Joint Commission Center for Transforming Health Care

    Reducing Colorectal Surgical Site Infections The Joint Commission’s Center for Transforming Healthcare aims to solve health care’s most critical safety and quality problems. Leading health care organizations partnered with the Center to use a proven, systematic approach to analyze specific breakdowns in patient care and discover their underlying causes to develop targeted solutions that solve these complex problems. In keeping with its objective to transform health care into a high reliability industry, The Joint Commission shares these proven effective solutions with the more than 20,500 programs it accredits and certifies. Also, part of the mission of the Joint Commission Center for Transforming Healthcare is to ensure the lessons learned and solutions developed can be applied to other health care organizations across the country.

    This project was launched in collaboration with the American College of Surgeons (ACS). The ACS is dedi- cated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment. The Reducing Colorectal Surgical Site Infections (SSI) project uses data derived from the ACS’s National Surgical Quality Improvement Program (NSQIP). Hospitals that participate in the ACS NSQIP program use trained surgical clinical reviewers to collect preoperative through 30-day postoperative data on randomly assigned patients. The collected clinical data allows ACS NSQIP to provide blinded, risk-adjusted data to share with all NSQIP hospitals, allowing them to nationally benchmark their complication rates and surgical outcomes. NSQIP data on outcomes of surgery are highly regarded by physicians as clinically valid, using detailed medical information on severity of illness and comorbidity to produce data on risk-adjusted outcomes. SSI is one of the most prevalent negative outcomes reported by NSQIP hospitals.*

    Colorectal Surgical Site Infections Project Participants • Cedars-Sinai Medical Center, Los Angeles, California • Cleveland Clinic, Cleveland, Ohio • Mayo Clinic-Rochester Methodist Hospital, Rochester, Minnesota • North Shore-Long Island Jewish Health System, Great Neck, New York • Northwestern Memorial Hospital, Chicago, Illinois • OSF Saint Francis Medical Center, Peoria, Illinois • Stanford Hospital & Clinics, Palo Alto, California

    *David B. Hoyt: “Looking Forward,” Bulletin of The American College of Surgeons, 2010;95(11):4-5

    Update: December 22, 2014

  • Colorectal Surgical Site Infection Project Outline

    * Key Terms • Correlating Variables are factors or attributes that are strongly

    associated with an outcome. For this project, participating hospitals analyzed and validated a number of variables that significantly influence the occurrence of colorectal SSIs within their organizations.

    • Contributing Factors are a set of actions leading to surgical pro- cess failure that increase the risk or likelihood of colorectal SSIs. Contributing factors are determined from correlating variables.

    • Targeted Solutions are practices developed to mitigate each contributing factor. They have been thoroughly tested and proven effective.

    Update: December 22, 2014


    Profile of Participants Page 3

    Why Colorectal SSIs? Page 4

    Colorectal SSI Project Results Pages 5-6

    Contributing Factors* & Targeted Solutions* Pages 7-10

    Measuring Colorectal SSIs Pages 11-13

    Correlating Variables* Page 14-16

    Sustaining Success Page 17









    Surgical site infections (SSIs) are the second most common healthcare-associated infection (HAI). SSI rates are disproportionately higher among patients following colorectal surgeries. Resulting SSIs are known to have significant patient complications with adverse clinical and economic impact. Quality improvement methods

    In partnership with the American College of Surgeons, the Joint Commission Center for Transforming Healthcare led a multi-institutional collaboration of seven leading U.S. hospitals, established to reduce colorectal SSIs. Preventing colorectal SSIs is a complex problem with multiple variables specific to patients and patient populations, institutional factors, surgical practice and process. Recognizing this complexity, participating hospitals used Lean Six Sigma and change management methods to understand why infections were occurring at their facilities and how to prevent them. Outcome measures were the observed rate of colorectal SSIs and the ACS NSQIP observed-to-expected (O/E) ratio for colorectal SSIs. Participants focused on improving the care received by colorectal surgical patients, from preadmission to 30-days after surgery. Results

    After two-and-a-half years, there was an overall reduction in superficial incisional SSIs by 45 percent and all types of colorectal SSIs by 32 percent. Participants attained cost savings of more than $3.7 million for the 135 estimated colorectal SSIs avoided during the project period. Applying the reduction in SSIs to the annual case load of colorectal surgeries at participating hospitals suggests that they will experience 384 fewer SSI cases and save $10.6 million per year as the result of this work. The average length of stay for hospital patients with any type of colorectal SSI decreased from an average of 15 days to 13 days.

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    Update: December 22, 2014

    Colorectal Surgical Site Infections: Characteristics of Project Participants


    Cedars-Sinai Medical Center

    Cleveland Clinic

    Mayo Clinic-Rochester Methodist Hospital

    North Shore-Long Island Jewish Health System

    Northwestern Memorial Hospital

    OSF Saint Francis Medical Center

    Stanford Hospital & Clinics






















    # of Beds

    # of Colorectal Surgeries/Month

    # of Colorectal Surgeries/Year

    # of Surgeons Performing Colorectal


    • The surgeons involved may be directly employed by the hospital, or be a mix of employed and private practice surgeons who perform surgeries at the participating hospitals.

    • Although two of the participating hospitals do not participate in the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP), all of the project participants agreed to use a common set of metrics to measure and monitor their colorectal SSI outcomes.

    • All of the project participants are academic medical centers.









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    Why Colorectal Surgical Site Infections? Surgical site infections (SSIs) are a major cause of patient injury and death. They increase health care costs and prolong hospitalization. In a 2002 study of U.S hospitals, the estimated number of healthcare-associated infections (HAIs) was approximately 1.7 million. SSIs were the second most common HAI, accounting for 22 percent of all HAIs among hospitalized patients. SSIs occur in 2-5 percent of patients undergoing inpatient surgery in the U.S., resulting in approximately 500,000 SSIs each year. Each SSI is associated with approximately 7-10 additional postoperative hospital days. Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI. Of SSI deaths among patients, 77 percent are directly attributable to SSI. SSIs are believed to account for up to $10 billion annually in health care expenditures. Attributable costs of SSI vary depending on the type of operative procedure and the type of infecting pathogen. Published estimates range from $3,000 to $29,000.

    Scope of the project

    A wide range of surgeries and procedures can result in SSIs – each with its own unique complications and challenges. To narrow the scope of the project, colorectal surgery was selected because it:

    • Is common across different types of hospitals. It is estimated that there are 300,000 to 600,000 patients who undergo colorectal surgical procedures annually across the U.S.

    • Has significant complications with an adverse clinical impact since the colon and rectal tracts contain more bacteria that are exposed during surgery

    • Presents hospitals with significant opportunities to improve performance • Has high variability in performance across hospitals

    The SSI project: • Includes all surgical inpatients undergoing emergency and elective colorectal surgery (following the ACS NSQIPs defined CPT

    codes), with the exception of trauma and transplant patients and patients under 18. • Addressed preadmission, preoperative, intraoperative, postoperative, and post discharge follow-up processes. • Includes all surgeons, ancillary professionals, infection prevention experts, as well as patients and their caregivers.

    Update: December 22, 2014

    Sources of data: Klevens RM, Edwards JR, et al: Estimating health care-associated infections and deaths in U.S. hospitals, 2002, Public Health Reports 2007;122:160-166

    Emori TG, Gaynes RP: An overview of nos