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Structure or Process Indicators

List the steps or key pieces that your clinical practice guideline or systematic review suggest that should be in place to improve outcomes (these become your measurements):

	Indicator	What data will be collected
1.	Heavy Nursing team	Average nurse-patient ratio
2.	P reoperative scrub completion	The amount of pre operative scrubs being reported complete
3.	Understaffed environment	Average ancillary staff on day shift
4.	Patient at home in dirty environment	Rate of newly diagnosed site infections at follow up
5.	Incorrect dressing being ordered for site	Rate of SSI with different types of dressings
6.	Nurse handoff not including site info	Amount of bedside shift report being done
7.	Education not to patient level of comprehension	Patient questionnaire
8.	Patient unable to demonstrate wound care	Patient evaluation of demonstration
9.	Not using best practice with infection control	Current infection control practice and rate of SSI
10.	Inpatient vs outpatient surgeries	Rate of SSI with inpatient surgeries vs outpatient

Plan for Improvement (for each item listed above, complete the following):

Indicator: Heavy Nursing Team

This is key to improving outcomes because: An appropriate nursing team would allow for adequate time for nursing cares to be completed to a high level.

Operational definition: Nursing team refers to the amount patients the nurse has under their individual care at once based on facility standards.

Numerator: Nurse

Denominator: amount of patients

Data collection method: Tracking amount of patients-nurse on given shift

Who	Nurse and patients
What	How many patients per nurse
Where	On a post-surgical unit in the inpatient setting
Why	The higher the ratio, the worse the outcomes for patients.
When	On day shift
How	Taking a total of the amount of patients per nurse at any given time.

Goal for this indicator: Decrease nurse-patient ratio to increase time available for nursing care.

Benchmark: Depends on floor. If we say a post-surgical floor, 4 patients-1 nurse on day shift.

Plan for Improvement (for each item listed above, complete the following):

Indicator: Patient not completing pre operative scrub before orthopedic surgery.

This is key to improving outcomes because: The patient who arrives in a hygienic state will likely have less micro organisms to be present when performing surgery.

Operational definition: A pre-operative scrub or shower is one that is completed by the patient prior to arrival for surgery with a specific scrub or soap indicated by the physician.

Numerator: patients who report completion of pre op surgical scrub

Denominator: orthopedic surgeries resulting in SSI

Data collection method: Questionnaire vs resulting SSI

Who	Patients receiving orthopedic surgery
What	Preoperative surgical scrub
Where	In inpatient setting and outpatient
Why	Preoperative scrub allows for less flora to be present during the procedure.
When	Prior to surgery and measured afterwards with SSI
How	Patient questionnaire when arriving and auditing amount of SSI in postoperative orthopedic patients.

Goal for this indicator: To lower SSI by ensuring preoperative scrubs are completed by the patient.

Benchmark 90%

Plan for Improvement (for each item listed above, complete the following):

Indicator: Lack of Ancillary staff

This is key to improving outcomes because: The larger teams for ancillary staff (C.NA, Techs, etc) allow for less patient mobility and activity to be completed when the nurse is completing nursing duties.

Operational definition: An ancillary staff member includes those under the nurse’s direction in the plan of care.

Numerator: Ancillary staff

Denominator: amount of patients being cared for

Data collection method: amount of staff per given shift

Who	Ancillary staff involved in the plan of care
What	How many patients ancillary staff are responsible for
Where	In the inpatient setting on a post-surgical floor
Why	The more availability the staff have to assist in the plan of care, the more active and hygienic the patient will be allowing for better wound healing.
When	On a day shift
How	Measuring the amount of patients per ancillary staff at any given time

Goal for this indicator: Increase amount of ancillary staff to assist nurses in completing the plan of care for the patient.

Benchmark: for C.NA on a post-surgical floor: 1:6 ratio

Plan for Improvement (for each item listed above, complete the following):

Indicator: patient home environment dirty

This is key to improving outcomes because: A non-hygienic home environment for the patient at discharge allows for more opportunity for infection.

Operational definition: Unsanitary home environment shown by amount of usable space in the home compared to the actual space available.

Numerator: Patient report of an unsanitary home

Denominator: amount of SSI at follow up

Data collection method: patient questionnaire and tracking new SSI diagnosed at follow up

Who	Patients who are being discharged home
What	Cleanliness of home
Where	Patient home
Why	Unsanitary living conditions can lead to more risk for infection at the surgical site
When	Patients returning for follow up visit
How	Tracking amount of new SSI at follow up with patients who have been home for a week

Goal for this indicator: To increase awareness for patients to have a sanitary living space when dealing with postoperative recovery to decrease SSI.

Benchmark 90% patients free of SSI at follow up

Plan for Improvement (for each item listed above, complete the following):

Indicator: Incorrect dressing being ordered for site

This is key to improving outcomes because: The correct dressing based on the orthopedic procedure will allow for the most optimal healing and infection prevention.

Operational definition: The dressing that is ordered by the provider to cover the surgical site.

Numerator: Basic wet to dry dressing order

Denominator: Amount of SSI

Data collection method: audit

Who	Provider ordering dressings
What	Type of dressing
Where	Inpatient or outpatient setting
Why	Selecting the optimal dressing for healing will decrease the rate of SSI
When	14 days postoperatively
How	Audit the amount of SSI when basic wet to dry dressing order used

Goal for this indicator: Decrease the amount of surgical site infections by utilizing the most efficient dressings for healing based on procedure.

Benchmark 90% patients free of SSI at follow up

Plan for Improvement (for each item listed above, complete the following):

Indicator: Nurse handoff report not including pertinent information.

This is key to improving outcomes because: Bedside shift report will improve transparency by directly showing characteristics of wounds and dressings.

Operational definition: Bedside shift report occurs when nurses complete patient handoff in the room that the patient is residing in, in front of the patient..

Numerator: amount of nurses doing bedside shift report

Denominator: number of those patients who develop SSI

Data collection method: audit

Who	Nurses working on orthopedic floor
What	Bedside shift report
Where	Orthopedic floor
Why	Bedside shift report will improve transparency by directly showing characteristics of wounds and dressings.
When	During day shift
How	Data collection via audit

Goal for this indicator: Increase the amount of nurses completing bedside shift report

Benchmark: 100% completing bedside report

Plan for Improvement (for each item listed above, complete the following):

Indicator: patient education not to level of comprehension for patient

This is key to improving outcomes because: Patients need to understand what they are being told to correctly follow through with instructions.

Operational definition: Patient education on discharge needs to be tailored to their health literacy.

Numerator: Patients who receive education at an 8th grade level

Denominator: rate of SSI at follow up

Data collection method: audit or questionnaire

Who	Nurses educating patients
What	Education regarding discharge or site management
Where	Inpatient or outpatient
Why	Patients need to understand what they are being told to correctly follow through with instructions
When	Prior to discharge after procedure
How	Collected via questionnaire for patient if they understood education or audit regarding prevalence of SSI at follow up.

Goal for this indicator: Improve SSI numbers by having patients who understand their discharge teaching related to wound care and infection control.

Benchmark 100% of patients stating they understand the education.

Plan for Improvement (for each item listed above, complete the following):

Indicator: Patient not able to demonstrate wound care

This is key to improving outcomes because: The patient needs to be able to demonstrate their own wound care in order to correctly prevent infection after discharge.

Operational definition: Demonstration of wound care by the patient includes the patient physical showing competence with performing the task of wound care.

Numerator: Patients who can demonstrate correct wound care

Denominator: SSI at follow up

Data collection method: audit

Who	Patients who had orthopedic surgery
What	Wound care by the patient
Where	Inpatient or outpatient setting
Why	Patient must be able to complete the skill of wound care when discharging and home care isn’t available.
When	Before discharge
How	Will be measured by audit to see if patient can demonstrate wound care.

Goal for this indicator: Decrease SSI by ensuring patients can complete their own wound care upon discharge.

Benchmark 100% of patients can demonstrate wound care.

Plan for Improvement (for each item listed above, complete the following):

Indicator: Poor infection control/not using best practice

This is key to improving outcomes because: Best practice with infection control would prove to decrease SSI based on research and proven evidence.

Operational definition: Best practice is derived from reviewed nursing research on the issue at hand.

Numerator: Orthopedic units with outdated best practice models for infection control

Denominator: number of SSI

Data collection method: audit

Who	Employees of the unit
What	Outdated best practice for infection control
Where	Inpatient orthopedic unit
Why	Infection control needs to be updated with current evidence to best provide safe and effective care.
When	Any given shift
How	Audit on current protocols vs. number of SSI

Goal for this indicator: Update protocols to reflect current best practices and EBP regarding infection control

Benchmark 100% of units audited changing to current best practices

Plan for Improvement (for each item listed above, complete the following):

Indicator: attempting to schedule more outpatient vs. inpatient surgeries

This is key to improving outcomes because:

Operational definition: An outpatient surgery is one that is planned for likely more than one week and does not require hospitalization. An inpatient surgery requires hospitalization and can be considered urgent or emergent.

Numerator: amount of outpatient orthopedic surgeries

Denominator: amount of inpatient orthopedic surgeries

Data collection method: audit

Who	Patients undergoing orthopedic surgery
What	Inpatient vs outpatient surgery
Where	Surgery center
Why	Outpatient surgeries likely have more time prepare and educate the patient compared to inpatient surgeries that may be rushed and allow less time to prep the patient.
When	When surgery occurs
How	Audits for type of surgery compared to SSI resulting

Goal for this indicator: Attempt to schedule as many surgeries as outpatient as possible in attempt to decrease rate of SSI with more prep time and planning.

Benchmark: 70% surgeries outpatient