Barton Healthcare System in South Lake Tahoe, California, shares its Sepsis (SEP-1) performance improvement implementation strategy.
Prior to implementation of the Sep-1 Early Management Bundle, Severe Sepsis/Septic Shock measure, Barton Health started to prepare its staff members by first auditing its baseline data from 2014 to identify opportunities for improvement. Based on that performance data and the Core Measure requirements, Barton Health identified gaps in its processes and built clinical education to address those gaps, which included simulation training to provide scenarios to frontline staff members in the emergency department (ED), urgent care, and inpatient units.
Using its electronic health record (EHR) software, a multidisciplinary team built order sets to standardize the care across departments. The EHR software also generates reports that monitor the compliance of frontline staff members using the order sets. In working with physicians, the ED medical staff director engages the ED physicians when opportunities are identified.
A quality specialist/core measure registered nurse performs concurrent medical record reviews and provides real-time feedback to the staff members who are caring for the patients. New staff members and physicians undergo training on the Sepsis Core Measure, and a reference tool was developed and is posted near workstations. Quality improvement staff members report performance on a quarterly basis at medical staff member meetings to the Board Quality Committee and Governing Board. Barton Health celebrates its successes and posts results in each department on public-facing quality boards. To achieve success, it took the work of a system-wide multidisciplinary team!
For more information, please contact Christine O’Farrell RN, BSN, CPHQ, CPHRM, Director of Quality Management, Barton Healthcare System, at email@example.com.