Pulling the Team Together: Surgical Site Infections

General

In starting a quality improvement (QI) project, realize that in many cases resistance will come both from the complexity inherent within the system and the ingrained hierarchical culture. A strong, well-led team is perhaps the most effective strategy to address these barriers.

Team Leader

There is a science to leadership for improvement and effective management of resources. Initial steps include knowing who, how, and when to ask for resources. Strong leaders endeavor to know the skills, abilities, and strengths of team members. Tasks should be distributed accordingly. The team leader should help the team identify the overarching goal. Keep the team focused on the overall goal and build consensus between team members and between various stakeholders.

Establish Team Rules

IDENTIFY AIMS: Identify the overarching role of the Surgical Site Infections QI team. Define this as precisely as possible. Write it down! Gain consensus among all team members.

ESTABLISH ROLES: Identify various content areas for team members. Clear, well-defined roles will allow individuals to "take ownership" of a portion of the QI project. Many times assigning ownership will occur after the interventions/tasks have been discussed and finalized.

SET TASKS: Identify as clearly as possible who will do what by when.

BUILD RAPPORT: This can often be accomplished by establishing certain ground rules.

1. Ensure that the discussion environment is open and safe — consider all ideas fairly; avoid ad hominem attacks (address the problems not the people)
2. Inclusive —value all potential contributors including diverse views. It's often helpful to ask for feedback from junior members of the team. If you start with senior members and they don't offer any views, junior members will often not contribute.
3. Consensus seeking —find a solution acceptable enough that all members can support it, and no member opposes it. In particular, consensus does not mean a unanimous vote (consensus may not represent everyone's first priorities) or a majority vote (in a majority vote, only the majority gets something they are happy with; people in the minority may get something they don't want at all, which is not what consensus is all about). The keys to achieving consensus include discussion, with good communication and willingness to compromise.

Quality Improvement Champion

The QI champion, who may or may not be a physician, should be someone with QI experience. The QI champion plays the pivotal role of ensuring that the team functions constructively and that the project stays on track. This role requires project management skills and at times may call for the ability to balance team dynamics or introduce appropriate QI tools. Mastery of the topic literature is not required; rather, a general understanding and acceptance of QI methodology are needed. The QI champion need not be an expert on QI tools at the outset but should have a readiness to acquire new tools and a talent for moving projects forward. Often the QI champion simply helps the team keep systems errors as the focus rather than individuals. For smaller-scale projects, the team QI champion could be the same person as a team leader, but for more ambitious projects or for projects involving buy-in from disparate physician and nursing groups, a separate champion is strongly recommended.

Content Experts

Although the team leader ensures cooperation and the functioning of the team and the QI champion focuses the attention on systems processes, content experts can provide invaluable assistance in obtaining buy-in and local treatment guidelines. Some suggestions include:

• ID: An ID physician may provide information on local rates of infection and resistance. She or he may be able to communicate more effectively with lab personnel in order to expedite speciation and sensitivities and disseminate local antibiograms and resistance patterns.
• PHARMACYy: Pharmacists can be invaluable allies in providing information and examples including how antibiotics are utilized in the emergency room, expediting approval for restricted antibiotics, automatic toxicity monitoring, or automatic discontinuation.
• ENDOCRINE: An endocrinologist or a glycemic control team will be helpful for improving blood glucose control. Please refer to the SHM Glycemic Control Resource Room for more information.
• SURGERY: Some surgical fields such as vascular or orthopedics may have pathways in place to address the level of amputation. Podiatry can often expedite debridement when infections are confined to the foot.

Content experts may be helpful for reviewing and summarizing the relevant literature, including its applicability to your institution and patient population. These individuals may be more aware of the metrics available to assess the success of your QI project. They will be invaluable in reviewing and formulating order sets, protocols, and educational materials and will lend authority to the team's recommendations and interventions.

Process Owners

Recognize that certain people on the front lines already are "experts" in the things they do. Obtaining buy-in from these individuals will help to ensure that work-flow disruption is minimized and that new changes/improvement steps are well accepted. Generally, process owners should come from each service (pharmacy, nursing, etc.) and geographic area (medical, surgical, ICU, etc.).

IT/HIS Experts

From performance tracking to actual QI interventions, the contributions of information technology or health information system experts will be pivotal. Enlist those who can report ICD-9 code frequencies at discharge, perform data entry, can set up reports from the electronic clinical data warehouse and radiology, and who can be a liaison to medical records. In other words, these experts can provide you and your team with data.

Effective Team Behaviors and Dynamics

Studies of health care teams have demonstrated certain behaviors that can lead to more effective teams.^1-4 How team members interact with one another is critica,^l and teams should strive to remove authority gradients. Because the perspective of every team member is potentially critical, every perspective must be heard. For this to happen, team members must be comfortable expressing their viewpoints. Try to pick people who have reputations for being collaborators. It is up to the leader and the facilitator to enforce constructive team dynamics.

Although meetings with the whole team are invaluable, they can occasionally become impractical or impossible to schedule. Team "huddles," where a fragment of the team meets briefly to advance action items, can be very effective for overall progress.

Team Behaviors and Dynamics

1. Pizzi L, Goldfarb N, Nash D. Crew resource management and its applications in medicine. In: Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment: AHRQ Publication No. 01- E058. 2001;43:501–509.
2. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res. 2002;37:1553–1581.
3. Baker DP, Gustafson S, Beaubien JM, Salas E, Barach P. Advances in patient safety: medical team training programs in health care. Washington, DC: American Institute for Research; 2004.
4. Wilson KA, Burke CS, Priest HA, Salas E. Promoting health care safety through training high reliability teams. Qual Saf Health Care. 2005;14:303–309.