What works? Early recognition It is important that we educate our - - PDF document

Surviving Sepsis: University of South Florida Graduate Medical Education and Tampa General Hospital's Quality Improvement Journey September 10, 2018

• Early recognition

– It is important that we educate our communities

• As many as 87% of sepsis cases originate in the patient’s community

– EMS ‐ First responder training and sepsis alert protocols – In‐hospital ‐ Frequent assessment using established criteria

• The Surviving Sepsis Campaign Bundle: 2018 Update

– The 3‐h and 6‐h bundles have been combined into a single “hour‐1 bundle” with the explicit intention of beginning resuscitation and management immediately.

• Measure lactate level.

– Remeasure if initial level is >2mmol/L

• Obtain blood cultures prior to administration of antibiotics
• Administer broad‐spectrum antibiotics
• Begin rapid administration of 30ml/kg crystalloid for hypotension or lactate

>4mmol/L

• Apply vasopressors if patient in hypotensive during or after fluid resuscitation

What works?

Sepsis Post‐op Rate

BL O‐16 N‐16 D‐16 J‐17 F‐17 M‐17 A‐17 M‐17 J‐17 J‐17 A‐17 S‐17 O‐17 N‐17 D‐17 J‐18 F‐18 M‐18 A‐18 M‐18 FL Rate 6.84 5.42 5.48 6.29 4.80 3.92 5.98 5.17 3.94 3.78 4.94 4.92 4.65 4.28 4.06 4.01 4.84 4.47 5.27 3.56 5.78 HRET HIIN Rate 4.72 3.78 3.98 3.82 3.84 3.58 3.52 3.75 3.43 3.36 3.74 3.36 3.61 3.37 3.53 3.50 3.91 3.88 3.85 3.38 3.58 # FL Reporting 73 67 68 68 70 70 70 69 69 70 69 69 70 69 69 69 67 67 66 65 63 #HRET HIIN Reporting 1,006 1,097 1,094 1,097 1,116 1,115 1,114 1,088 1,089 1,089 1,080 1,083 1,084 1,017 1,014 1,010 1,009 1,001 1,002 881 855

0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00

Rate per 1,000

Source: Comprehensive Data System, September 9, 2018

Overall Sepsis Mortality

BL O‐16 N‐16 D‐16 J‐17 F‐17 M‐17 A‐17 M‐17 J‐17 J‐17 A‐17 S‐17 O‐17 N‐17 D‐17 J‐18 F‐18 M‐18 A‐18 M‐18 FL Rate 154.8 151.2 150.4 141.5 163.7 145.5 150.2 151.9 127.5 139.6 157.1 135.8 150.0 144.7 136.3 149.2 163.4 129.5 135.6 138.9 118.3 HRET HIIN Rate 130.6 115.5 118.5 118.3 129.3 122.8 121.6 120.6 103.8 109.8 113.3 108.1 112.0 113.2 113.0 120.7 130.6 123.8 115.8 118.2 100.3 # FL Reporting 68 72 72 72 72 72 72 72 72 69 69 68 69 68 68 68 66 64 65 64 64 #HRET HIIN Reporting 1,156 1,341 1,344 1,354 1,366 1,364 1,366 1,354 1,348 1,331 1,325 1,322 1,327 1,315 1,289 1,278 1,270 1,260 1,259 1,131 1,107

0.0 25.0 50.0 75.0 100.0 125.0 150.0 175.0

Rate per 1,000

Source: Comprehensive Data System, September 9, 2018

Hospital‐Onset Sepsis Mortality Rate

BL O‐16 N‐16 D‐16 J‐17 F‐17 M‐17 A‐17 M‐17 J‐17 J‐17 A‐17 S‐17 O‐17 N‐17 D‐17 J‐18 F‐18 M‐18 A‐18 M‐18 FL Rate 238.33 247.00 256.68 267.44 313.77 250.00 287.26 273.22 264.06 313.25 303.03 257.81 299.38 323.67 232.00 306.12 320.65 238.81 254.55 290.80 292.17 HRET HIIN Rate 135.11 205.30 206.44 215.50 255.45 233.00 235.98 234.86 189.33 193.61 173.26 166.27 168.66 200.49 200.90 239.46 204.50 205.11 219.94 231.25 206.43 # FL Reporting 55 56 55 56 56 56 56 56 56 55 55 55 56 55 55 55 53 51 51 50 50 #HRET HIIN Reporting 1,104 1,260 1,262 1,269 1,279 1,276 1,270 1,256 1,250 1,251 1,250 1,245 1,249 1,238 1,222 1,212 1,210 1,199 1,198 1,102 1,074

50 100 150 200 250 300 350

Rate per 1,000

Source: Comprehensive Data System, September 9, 2018

• Change Packages and Top 10

Checklists

• Date of Last Septic Event Poster
• Post‐op Prevention Process

Improvement Discovery Tool

• Sepsis Podcast
• LISTSERVs

MTC HIIN Resources

HRET HIIN Website: www.hret‐hiin.org

• Webinars and Coaching Calls
• National Experts
• Quality Improvement Fellowships
• Patient and Family Engagement

Learning Collaborative

• Chasing Zero Infections Series
• Safety Culture Survey
• UP Campaign – SOAP UP, GET UP,

WAKE UP, SCRIPT UP

MTC HIIN Resources

FHA MTC HIIN Website: www.fha.org HRET HIIN Website: www.hret‐hiin.org

HRET HIIN Quality Award Winner

Congratulations, Florida Hospitals! Outstanding performance in driving quality care, safety and value across its network of hospitals

AH AHA Lead A Leader ershi ship Summ Summit HII HIIN Recept Reception, July July 25, 201 25, 2018

HRET

2018 High Performance Award

Florid ida Hos a Hospit ital al Ass Association

In Support of the Partnership for Patients Program

MTC HIIN Upcoming Events

• Sep. 12 ‐ QI Fellowship Office Hours #10
• Sep. 13 ‐ Patient & Family Engagement Convening [Orlando, FL]
• Sep. 14 ‐ CDI Sprint Summary
• Sep. 18 ‐ Reduce Readmissions: Florida Rx Card
• Sep. 18 ‐ Sepsis Alliance: Pearls and Pitfalls in the

Recognition & Treatment of Pediatric Sepsis

• Sep. 20 ‐ Surviving Sepsis: Learn How Florida Hospital New

Smyrna Reduced Sepsis Mortality

• Sep. 21 ‐ Fall Injury Prevention Strategies
• Oct. 16 ‐ TeamSTEPPS Check‐in Webinar

Check the MTC HIIN Upcoming Events Calendar for details and registration

We are here to help! HIIN@fha.org | 407‐841‐6230

State Lead: Kim Streit, FACHE, MBA, MHS, VP, Health Care Research & Information Svcs. Improvement Advisors: Cheryl Love, RN, BSN, BS‐HCA, MBA, LHRM, CPHRM, Director, Quality & Patient Safety Phyllis Byles, RN, BSN, MHSM, BC‐NEA, Clinical Performance Improvement Advisor Dianne Cosgrove, MS, RN, CPHQ, LHRM, Director of Clinical Quality Improvement Communications: Luanne MacNeill, Quality Initiatives Coordinator Data Support: Debbie Hegarty, Manager of Surveys & Special Projects Fellowships & Patient and Family Engagement: Allison Sandera, MHA, Project Manager

Contact Us

9/9/18 1

Surviving sepsis:

USF GME & TGH’s quality improvement journey

Maya Balakrishnan, MD, CSSBB Associate Professor, USF Pediatrics Joint Associate Professor, USF COPH Director of Quality and Safety, USF GME Associate Director, FPQC FHA webinar 9/10/18

Disclosure statement

• I have no relevant financial relationships with

manufacturers of any commercial products or providers of commercial services discussed in this activity.

• I do not intend to discuss an unapproved or investigative

use of a commercial product or device in my presentation.

Engaging interprofessional teams

in quality improvement can decrease sepsis-related mortality

• 1. Discuss opportunities for promoting

interprofessional teamwork & QI at TGH & USF

• 2. Apply the Model for Improvement to address

sepsis

Engaging interprofessional teams

in quality improvement can decrease sepsis-related mortality

• Promote meaningful engagement in QI activities
• Focus on improving communication
• Working in interprofessional teams

Empower health professionals to advocate for safe, quality patient care.

USF GME TGH USF Our problem...

Patient outcomes can be improved by the implementation of QI initiatives

USF Morsani College of Medicine USF College of Nursing USF College of Public Health

...

Limited clinical opportunities to apply QI learning

9/9/18 2 Our problem...

Patient outcomes can be improved by the implementation of QI initiatives

USF Morsani College of Medicine USF College of Nursing USF College of Public Health

...

Limited clinical opportunities to apply QI learning TGH is the major academic affiliate for USF physicians

Our problem...

Patient outcomes can be improved by the implementation of QI initiatives

Meaningful engagement in QI activities

(education, support, communication)

Our problem...

Patient outcomes can be improved by the implementation of QI initiatives

Efficient & effective use of existing resources

(interprofessional teamwork)

Our problem...

Patient outcomes can be improved by the implementation of QI initiatives

Choosing QI initiatives aligned with

• rganizational

goals

Think big

Patient outcomes can be improved by the implementation of QI initiatives

Choosing QI initiatives aligned with

• rganizational

goals Efficient & effective use of existing resources

(interprofessional teamwork)

Meaningful engagement in QI activities

(education, support, communication)

1 Agency for Healthcare Research and Quality: Healthcare Cost and Utilization Project Statistical Brief No. 160. National inpatient hospital costs:

the most expensive conditions by payer, 2011. 8/2013. 2 Alberti C et al, Epidemiology of sepsis and infection in ICU patients from an international multicenter cohort study, 2002. Intensive Care Med, 28: 108-21. 3 Angus DC et al. Severe sepsis and septic shock. N Engl J Med 2013; 369: 2063.4 Engel C et al. Epidemiology of sepsis in Germany: results from a national prospective multicenter study. Intensive Care Med, 2007; 33: 606-18. 5 Vizient Database, TGH report 2016. 6 CDC. Inpatient care of septicemia or sepsis: A challenge for patients and hospitals. 6/22/11. 7 Walkey AJ et al. Hospital case volume and outcomes among patients hospitalized with severe sepsis. Am J Respir Crit Care Med, 2014; 189: 548-55.

Mortality increases by 7% for every hour that sepsis treatment is delayed3

>50%

develop severe sepsis7 Of those

~25%

develop septic shock7

403

adults at TGH died (2016)5

#1

cause of inpatient deaths nationally1

Hospital mortality ~30-50%2-4

Preventing severe sepsis can save lives

9/9/18 3

Preventing sepsis can avoid hospital days

1 Kauffman Halll. Length of stay committee meeting. KHA presentation, 7/24/17. 2 Alberti C et al, Epidemiology of sepsis and infection in ICU

patients from an international multicenter cohort study, 2002. Intensive Care Med, 28: 108-21. 3 Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med, 2017; 45: 486-552.

Sepsis is the most expensive condition treated in US hospitals, costing more than $20 billion2

15% of all

ICU admissions7

>750,000

US hospitalization/year6

2,127

excess days of care at TGH (2016-2017)

morbidity mortality length of hospital stay costs (direct, indirect, quality of life)

Sepsis is a healthcare problem

Compliance with evidence-based Surviving Sepsis Campaign recommendations for acute management of sepsis & septic shock resulted in significant decrease in hospital mortality & length of hospital & ICU stay1

• Surviving Sepsis Campaign launched in 2002 with goal of

reducing sepsis by 25% in the following 5 years2

• Demonstrated decrease in unadjusted odds ration for

hospital mortality from 37% to 30.8% over 2 years (p=0.001)1

– Compliance to the Resuscitation bundle (1st 6 hours) & Management bundle (1st 24 hours) is possible

1 Levy MM et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a. 7.5 year study. Crit Care

Med, 2015; 43: 3-12. 2 www.survivingsepsis.org

QI in healthcare

1. Oh W, Berns SD, Blouin AS, Campbell DE, Fleischman AR, Gluck PA, O’Kane ME, Santa-Donato A, Simpson KR, Stark AR, Wachtel JS. Toward Improving the Outcomes of Pregnancy III. March of Dimes. August 2011. 2. Institute of Medicine. Shaping the Future for Health. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999.

Quality is defined…1,2

What & how well something is done

AND

Doing the right thing à delivering needed healthcare services At the right time à when patients need them In the right way à using appropriate tests/procedures

Variation is everywhere

Goals

• Understand variation
• Control degree of variation
• Minimize its impact

Decrease variation àdeliver service in a predictable manner àproduce a predictable & reliable result

9/9/18 4 Does variation in sepsis rates make it a suitable problem to address using QI methods?

Knowledge systems for QI

Generalizable scientific evidence

+ Particular

Context Measured Performance Improvement

From empirical studies that try to eliminate effects of context Characteristics

• f the local

setting or environment Measurement

• ver time

Balanced measures Knowledge about applying, adapting evidence to context Knowledge needed for execution, change

Batalden & Davidoff. Qual Saf Health Care. 2007: 16: 2-3. Slide adapted & used with permission from Dr. Gautham Suresh

IHI’s Model for Improvement

Plan Do

Study Act

What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?

Plan Do

Study Act

What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? qUnderstand the problem qDetermine the aim qForm interprofessional team

9/9/18 5 Our sepsis problem statement

Compliance with sepsis-related guidelines at TGH is suboptimal leading to increased patient mortality & cost. The Vizient database comparison of academic medical centers reports TGH’s compliance with the SEP-1 bundle was below average in performance & sepsis mortality index was in the lowest quartile (AY 2016).

AY: Academic year

Our sepsis aim statement

By 6/2019, we will improve our compliance with the TGH sepsis bundle to the current average academic medical center performance of 35%.

1 Core team members include: Attending project lead, Resident project lead, Data

lead, Administrative lead, & identified TGH inter-professional partner

Research Improvement

Aim New knowledge Improvement in care Test Blinded or controlled test Observable test Bias Design to eliminate bias Accept consistent bias Sample size Just in case data Just enough data, small sequential samples Hypothesis flexibility Fixed hypothesis Hypothesis flexible & changes as learning takes place Testing strategy One large test Sequential tests Determining if a change is an improvement Hypothesis tests, statistical tests, p values Run charts or Control charts Data confidentiality Research subject identities are protected Data used only by those involved with improvement

Lloyd CR. Navigating the Turbulent Sea of Data: The Quality Measurement Journey. Clinics in Perinatology, 2010. 37(1): 101-122.

Plan Do

Study Act

What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? qDevelop clear measures

Data type Definition

Outcome

• Measures effectiveness
• How does the system impact the values of

patients, their health, & wellbeing?

• What are impacts on other stakeholders (i.e.,

payers, employees, community)? Process

• Measures internal to the process
• Are parts or steps in the system performing as

planned?

• Are we on track in our efforts to improve the

system? Balancing

• Are improvements designed to improve 1 part
• f the system causing new problems in other

parts of the system?

QI tries to evaluate efficiency & effectiveness of interventions using measures Balanced set of 5-8 measures usually enough

Data type Definition

Outcome

Aim: 2-3 Achieve what we set out to do?

• Measures effectiveness
• How does the system impact the values of

patients, their health, & wellbeing?

• What are impacts on other stakeholders (i.e.,

payers, employees, community)? Process

Aim: 1-8 How the change happens

• Measures internal to the process
• Are parts or steps in the system performing as

planned?

• Are we on track in our efforts to improve the

system? Balancing

Aim: 1-2 Cause harm inadvertently?

• Are improvements designed to improve 1 part
• f the system causing new problems in other

parts of the system?

9/9/18 6

Plan Do

Study Act

What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? qUnderstand the current process qPerform a gap analysis qGenerate ideas for tests of change qDevelop key driver diagram

• Systematic method to outline a QI initiative
• Shared team view on theory of change
• Predicts system changes that help progress towards aim
• Shows cause & effect (“causality”)
• Helps others understand what you need to be successful
• Define key leverage points (drivers) in a system
• Increase your chances for project success

Key driver diagram Key driver diagram

34

Desired

• utcome

SMART AIM Key Drivers “Big Changes” or concepts Most likely to achieve aim

Aim Primary Drivers

Specific actions Support primary drivers “Small changes” that are testable &measureable

Secondary Drivers (AKA interventions)

Direction of causality

https://app.smartsheet.com/b/home?lang=en_US By 6/2019, we will improve our compliance with the TGH sepsis bundle to the current average academic medical center performance

• f 35%1

Improve readiness to address sepsis Improve recognition

• f sepsis

Improve prevention

• f sepsis

Improve response to sepsis Improve reporting

• f sepsis

Assess invasive device necessity daily Standardize & consistently use a sepsis algorithm, orders, & guideline Communicate expectations with patients & family Appropriately supporting & de-escalating care Perform safe & effective transitions of care Use a trigger tool Document the exam, diagnosis, & response to interventions Compliance with the sepsis bundle Use infection prevention strategies Use appropriate sepsis definitions

• V1. 9/2017

1 Based on AY 2017

Vizient data

Key drivers identify project measures

Helps ensure the team is collecting relevant measures to affect your aim

Process measures Outcome measure

9/9/18 7 Value of standardized processes

Processes should be standardized before improvement can begin

• Baseline for QI activities
• Where is a process?
• Where is the process going?
• How is the process getting there?

Lean Six Sigma course. Benchmarking. Munson. Villanova University.

Goal of standardization in Industry Consistently produce good service(s) or product(s) that meet agreed-upon requirements Goal of standardization in Healthcare Consistently produce good health outcomes that meet agreed-upon goals

A process by which healthcare products or services are chosen by a committee of key stakeholders, taking into account evidence-based results, to ensure quality patient care while adhering to fiscal responsibility

How standardization has been applied

INDUSTRY

• Electrical plugs & sockets
• Computer connections
• Diesel vs. gasoline nozzles
• Standard operating

procedures in aviation

• Computer coding

HEALTHCARE

• WHO High 5’s project
• CLABSI reduction
• Neonatal Resuscitation

Program

• Newborn screening
• GBS (intrapartum prophylaxis

& neonatal management)

• Neonatal HIV management

Make it easier to do the right thing

Standardization should not be applied to everything. Everything should not be standardized.

9/9/18 8

Standardizing a process

Find a process Develop a guideline

Know when to customize

Use measurement

• 1. Find a suitable process to standardize
• Supported by high-quality evidence
• Repeatedly done in the same way every time
• Affects a homogenous population of patients
• Engages a large population of practitioners

performing high-stakes tasks

• Agreed upon by stakeholders

Standardizing a process

Find a process Develop a guideline Know when to customize Use measurement

• 1. Find a suitable process to standardize
• 2. Develop a guideline

....& have compliance with the guideline Understand limitations to guidelines

• Not understanding the local environment
• Inability to adapt systems to work in setting created for
• Using low-quality evidence
• Lack of guideline consensus or compliance
• Behaviors
• Medico-legal considerations

Standardizing a process

Find a process Develop a guideline Know when to customize Use measurement

• 1. Find a suitable process to standardize
• 2. Develop a guideline
• 3. Know when to customize

Standardizing a process

Find a process Develop a guideline Know when to customize Use measurement

• 1. Find a suitable process to standardize
• 2. Develop a guideline
• 3. Know when to customize
• 4. Use measurement

Our theory of change

• 1. Providing resources & a structured interprofessional

approach to QI may promote sustained QI engagement amongst GME faculty, GME trainees & TGH health professionals

• 2. Promote sepsis bundle compliance along the continuum of care

for adult & pediatric patients may improve overall TGH sepsis bundle compliance

9/9/18 9

Plan Do

Study Act

What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? qTest interventions

Interventions our teams have addressed

STANDARDIZE

• Sepsis guideline
• Sepsis checklist
• Method of “Time Zero”

identification (i.e., sepsis alert)

• EMR order set
• EMR note template
• Education

1 Currently being developed and implemented

IMPROVE COMPLIANCE

• Document response to

interventions performed

• IV fluid administration (dose,

type)

• Shared patient handoff1

USE TOOLS

• EMR trigger tool (predictive

analytics)

• EMR report

What is a PDSA cycle?

• Useful tool for developing & documenting tests of

change to improve

• AKA PDCA, Deming Cycle, Shewart Cycle

P – Plan a test D – Do a test S – Study & learn from test results A – Act on results

• 1. Plan
• 2. Do
• 3. Study
• 4. Act

Deming WE. The New Economics for Industry, Government, and Education. Cambridge, MA: The MIT Press; 2000.

Reasons to test changes

Learn whether change will result in improvement Predict the amount of improvement possible Evaluate the proposed change work in a practice environment Minimize resistance at implementation

By 6/2019, we will have >50% improvement from baseline compliance with the IM/PCC sepsis bundle in patients >18 years

• f age

admitted to USF IM services at TGH Recognition

• f sepsis

Revise & demonstrate compliance with a standardized sepsis

• rder set

Reporting of sepsis

Handoff tool compliance (providers: includes documentation of 0,3, & 6 hour time stamps; RN: includes patient’s progress with bundle) Ensure appropriate consults placed to ID & Palliative care

INTERVENTIONS

GME-TGH Sepsis QI initiative – Internal Medicine/Pulmonary Critical Care Implementation of Sepsis predictive analytics list to identify sepsis patients Internal Medicine/Pulmonary Critical Care sepsis bundle includes all of the following: 1) Documentation of Time 0, 3-hour, & 6-hour interventions, and 2) Use of the sepsis order set

Response to sepsis

Compliance with administering IV fluids when there is hypotension or elevated lactate Compliance with obtaining lactate (initial and follow up) Compliance with obtaining blood culture before antibiotic administration Compliance with obtaining appropriate imaging to confirm source Administer broad-spectrum antibiotics w/in 1 hour of time 0 Revise & demonstrate compliance with a standardized sepsis note on initial presentation and follow-up when indicated Complete provider and nursing sepsis education

Plan-Do-Study-Act

• Have an objective
• Concisely state what you plan to do
• I plan to...Introduce a standardized physician EMR note

for sepsis patients in the Pulmonary Critical Care Unit

• Make a prediction
• Execute the plan

What are we trying to accomplish?

9/9/18 10 Plan-Do-Study-Act

• Have an objective
• Make a prediction of what will happen
• I hope this produces... improvement in reporting of

sepsis

• Execute the plan
• Have an objective
• Make a prediction
• Execute the plan

Who? Pulmonary Critical Care Unit residents & fellows will use note with any sepsis patient What? EMR note template (EPIC “dot phrase”) When? 2 weeks Where? Pulmonary Critical Care unit How data will be collected? Sepsis patients identified by existing trigger tool; EMR review of identified sepsis patients

Plan-Do-Study-Act Plan-Do-Study-Act

• Have an objective
• Make a prediction
• Execute the plan

How will we know that a change is an improvement?

Plan-Do-Study-Act

• Have an objective
• Make a prediction
• Execute the plan

What changes can we make that will result in improvement?

Plan-Do-Study-Act

• Do the test
• Take notes on problems & observations
• Access to the EMR note template?
• Was it easy to use?
• What did stakeholders like & dislike about the EMR note

template?

• Know when to stop the test
• Can terminate before designated time frame if the test

clearly doesn’t work

Plan-Do-Study-Act

Yes

9/9/18 11 Plan-Do-Study-Act Plan-Do-Study-Act

Refine next cycle based on what was learned

Keep in mind

• Scale down scope of tests
• Pick willing volunteers
• Choose changes that don’t require long

process for approval initially

• Don’t reinvent the wheel

Keep in mind

• Pick easy changes with good yield
• Avoid technical slow downs
• Reflect on results of EVERY change – even

failures

• End the test if there is no improvement

Cycle Date Intervention 1 11/2017 Completed QI boot camp sessions 1 & 2 2 1/2018 Team’s 1st PDSA cycles, QI coaching offered at request 3 4/2018 Predictive analytics used 4 6/2018 Release of most EPIC EMR tools 1 2 3 4 Cycle Date Intervention 1 11/2017 Completed QI boot camp sessions 1 & 2 2 1/2018 Team’s 1st PDSA cycles, QI coaching offered at request 3 4/2018 Predictive analytics used 4 6/2018 Release of most EPIC EMR tools 1 2 3 4

9/9/18 12 Engaging interprofessional teams

in quality improvement can decrease sepsis-related mortality

Using a structured approach is key

to facilitating continuous quality improvement

Maya Balakrishnan, MD, CSSBB

mbalakri@health.usf.edu or fpqc@health.usf.edu