PDSA Worksheet for Testing Change

Aim: (overall goal you wish to achieve)

Decrease rate of surgical site infections (SSI) observed in outpatient orthopedic ambulatory surgery center
(ASC).

Every goal will require multiple smaller tests of change

Describe your first (or next) test of change: Person When to Where to
responsible be done be done
Determine baseline SSI rate for each physician and overall for the RN July ASC
ASC from previous year, set a goal for improvement for the Manager, 2015-
upcoming year overall, implement action plans, and evaluate Infection January
results in a sample of patients over the next six months. Control 2016
Supervisor
Plan
List the tasks needed to set up this test of change Person When to Where to
responsible be done be done
1) Put together a team, including the RN manager and Designated July ASC
infection control supervisor, to determine previous infection team 2015-
rates for ASC, implement changes to policy to improve SSI January
rates in the upcoming year, track changes, and evaluate 2016
final effectiveness.
2) Determine, based off the best current evidence, what
changes need to be implemented to reduce SSI rates.
Evidence should come from meta-analyses, systematic
reviews and RCTs. Example: The Institute for Health Care
Improvement released a best practice protocol for
preventing SSI - Griffin, F. A. (2005). Best-practice
protocols: Preventing surgical site infection. Nursing
Management, 36(11), 20.
3) Implement necessary changes into the ASC and
appropriately educate staff.
4) Continue to track SSI rates and evaluate current changes
for decrease in SSI rates over the next six months.
5) Determine if changes decreased overall SSI rates and
Institute for Healthcare Improvement
 PDSA Worksheet for Testing Change
should be permanently adopted into practice.

Predict what will happen when the test is carried
out
SSI rates will decrease by 5-10% as current best
practice measures are implemented into the ASC.
Do Describe what actually happened when you ran the test
Measures to determine if prediction succeeds
SSI rates are tracked by individual surgeons. The
surgeon is sent a list of patients in which surgery
was performed at ASC for the given month, and is
asked to check whether or not a SSI was present at
the patients first follow-up appointment. Overall
infection rates for the month are then calculated by
combining all surgeons outcomes to determine
percentage of SSI at ASC.

At the start of the small test of change, a team was assembled and designated to implement new guidelines
and track SSI for the ASC. This team included the ASC RN manager, as well as the Infection Control
Supervisor and Operating Room Team Lead. The team analyzed and compiled a new guideline for the ASC
after synthesizing the best evidence from multiple articles, meta-analyses, systematic reviews and RCTs.
They determined the best practice for prevention of SSI at an ASC was proper antibiotic administration,
proper regulation of patients body temperature, proper aseptic technique and hand washing by operating
room staff, appropriate hair removal techniques and glycemic control. Staff were then properly educated and
trained regarding these core measures. SSI rates were continually monitored over the following six-month
period to see if SSI rate did decrease following implementation of this new guideline. The ASC had an 85%
rate of patients without infections prior to implementation and following the new guidelines, this rate
improved to 95%.
t
Study Describe the measured results and how they compared to the predictions

Prior to the small test of change implementation, the ASCs rate of patients who did not experience any kind
of postoperative infection was 85%. Following implementation of the core measures recommended by
current best practice research, this rate increased to 95%. This means the actual infection rate decreased by

Institute for Healthcare Improvement

 PDSA Worksheet for Testing Change
10% over the six-month period. This is concurrent with the change initially predicted and validates the
overall goal of the study.

Continual staff education is needed to keep up the change, as well as, close monitoring of guidelines and
best practice recommendations. Guidelines are constantly evolving to include better methods, and the ASC
should stay abreast of these changes in order to keep infection rates low.

In the future, the ASC may want to consider involving other staff members involved in the patients care into
the training, such as contracted anesthesia staff. The ASC may also want to adopt a policy and procedure
for involving the patient and family in the care and monitoring by educating them during the preoperative and
postoperative phase via verbal education and professional literature.

Act Describe what modifications to the plan will be made for the next cycle from what you learned

1. Continue to track, monitor, and report on a quarterly to semi annual basis.

2. Continue to research the best practice guidelines for the prevention of SSI rates.
3. Continue to educate and properly train staff on the core measures implemented.
4. Consider involving additional staff and even the patients in the process.
5. Post results to keep staff and patients accountable, informed and interested in the SSI rates.

Institute for Healthcare Improvement