make briefing notes NBHRC Case Study Surgical Site Infection (SSI) Health Care is Us is a 430 bed hospital with a primary hospital site, a secondary hospital site and 5 other locations in 2 cities where services are provided. With respect to this assignment, the primary site is the only one involved in surgical procedures. The mission of Health Care is Us is Partnering in care, we restore and maintain health for mind and body. It is 2015 and you project manager responsible for supporting the implementation of the SSI toolkit for Health Care is Us (HCU). HCU has recently enrolled in the National Surgical Quality Improvement Program (NSQIP). NSQIP is a program implemented through the American College of Surgeons that measures the quality of surgical outcomes by tracking patients over 30 days from the time of surgery. It correlates indicators of surgical outcomes relative to other hospitals in the province, country, and North America. This includes Surgical Site Infections (SSI), which is defined as an infection that occurs within 30 days after operation of skin and subcutaneous tissue and includes at least one of: purulent drainage, organisms isolated from culture of fluid or tissue and at least one of: pain or tenderness, localized swelling, redness, heat, incision deliberately opened, diagnosed by surgeon as having an SSI. HCU has found that it is a consistent outlier for increased SSIs, with up to a 47% greater risk of developing an SSI at HCU compared to other hospitals within NSQIP. The implications of higher SSI rates are profound. In addition to an adverse event for the individual patient, higher SSIs lead to increased length of hospital stays, emergency visits, and hospital readmissions, with a considerable resultant financial burden. Your boss has asked you to support Dr. Singh who is Chief of Surgery in forming a project team with the objectives of choosing a bundle of tools and processes which we would implement to decrease SSIs. This project is intended to involve multiple stakeholders from various surgical disciplines. One of the expectations is to develop a bundle of quality improvement activities using evidence based methodology. The World Health Organization (WHO) has completed an extensive 3 year study to identify bundle elements. Examples of these elements are: pre- op skin bathing, pre-op warming, antibiotic re-dosing, glucose control, hair removal outside the OR, limiting traffic in the OR, double gloves, etc. The medical students have offered to help do a literature search as part of their requirements for the UME curriculum. In this assignment you do not have to create the bundle, but you do have to consider the approach to developing it. Your boss has reminded you that the approach to the project must be consistent with HCUs quality system which includes a Design Systems approach that embeds the following elements:

- Key stakeholder participation - Identification of project team members roles and responsibilities - Frequent and transparent communication - Data analysis and reporting - Obtaining real time feedback - Mitigating risks - Allocation of appropriate resources - Prioritization of project milestones and tasks -Plan Do Study Act (PDSA) to sustain the project Your boss has asked you to prepare a briefing note using the organizations standard template, documenting the approach to be taken to implement SSI over the first year of implementation. Fortunately, you have been learning all about change management and cant wait to show off your new skills