American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Back to Basics: Reducing Surgical Site Infection in the Open Abdominal Gynecology Surgical Population

Cleveland Clinic

General Information

Cleveland Clinic, Cleveland, OH
Nancy Anzlovar, RN, BSN, ACS NSQIP Surgical Clinical Reviewer

What Was Done?

Global Problem Addressed

The second most common hospital-acquired infection—surgical site infections (SSIs)—cost an estimated $3.4 billion to $10 billion dollars annually.1 These infections are associated with a high morbidity and mortality and place a large burden upon the inpatient health care budget. Under the Affordable Care Act and the Value-Based Purchasing model, hospitals are increasingly driven to lower health care costs and increase the quality of patient care by reducing the incidence of hospital-acquired conditions. 

Identification of Local Problem

Review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Semiannual Report from July 1, 2010 through June 30, 2011 demonstrated the gynecology (GYN) surgical subspecialty to be a high outlier for morbidity (10.60 percent observed/6.57 percent expected). SSIs were identified as the main driver of this metric (4.61 percent observed/2.34 percent expected). This corresponded to the tenth decile as well as high outlier status. After reviewing these results with key stakeholders of the Obstetrics and Gynecology (Ob/Gyn) & Women’s Health Institute, a decision was made to form a multidisciplinary quality improvement (QI) team to address this issue.

The improvement team analyzed 617 surgical cases from July 2008 through March 2011 using ACS NSQIP data. There were 26 superficial SSIs (4.2 percent), 3 deep SSIs (0.5 percent), and 9 organ/space SSIs (1.5 percent). Abdominal cases were found to have a higher incidence of SSI when compared to laparoscopic and vaginal surgical approaches.

How Was the QI Activity Put in Place?

Context of the QI activity

Cleveland Clinic is a 1,450-bed facility located in northeast Ohio. The clinic is organized into patient-centered institutes that combine the medical, surgical, and support functions for specific body systems or disorders. The Cleveland Clinic Health System is comprised of the main campus, eight community hospitals, and 18 family health centers as well as facilities in Florida, Nevada, Toronto, and Abu Dhabi. The scope of this initiative was gynecologic surgical cases on main campus only.

In 2011, Cleveland Clinic participated in a multi-institutional collaboration in conjunction with The Joint Commission for Transforming Healthcare and the ACS to reduce the incidence of SSI in the colorectal surgery population. This allowed for sharing of best practices among participants as well as the implementation of new processes. At Cleveland Clinic, a multifactorial approach was utilized to lower the wound infection rate. ACS NSQIP data was used throughout the project to establish the impact of these processes on surgical outcomes.

The Ob/Gyn & Women’s Health Institute employed the lessons learned from this initiative and applied similar improvement processes to their own practice.

Planning and Development Process

Based on regular review of ACS NSQIP data and the aforementioned analysis, abdominal cases were focused on exclusively. A total of 213 cases from July 2008 through March 2011 were reviewed and revealed an 8.5 percent rate of superficial SSI (18 cases) and a 4.2 percent rate of deep or organ/space SSIs (9 cases). The analysis demonstrated limited significant differences when comparing patient populations and clinical variables. Body mass index (BMI) was the only variable of statistical significance.

Upon completion of data analysis, the Quality Improvement Officer (QIO) within the institute reviewed the information and assembled a team directly involved with GYN surgery. This included a multidisciplinary team of care providers across the full care continuum. The scope of the project would be from the time a patient was scheduled for surgery to 30 days postdischarge, which was defined as a surgical episode. The chair of the Women’s Health Institute was involved at the outset and his sponsorship provided appropriate leadership to prioritize the effort and eliminate obstacles for the team.

During the planning phase, three distinct areas in the surgical episode emerged as opportunities for improvement: preoperative, intraoperative, and postoperative. Parallel teams were created and each team was tasked with their own process scope. The preoperative team focused on the period of time between a patient being scheduled for surgery and their arrival on the day of surgery. The intraoperative team concentrated on the time the patient was brought back to the preoperative area to the patient’s discharge from PACU. The postoperative team was charged with patient admission to the inpatient surgical unit, to 30 days postdischarge.

Once improvement opportunities were identified by each subteam, the entire group reconvened in an effort to prioritize ideas based on clinical evidence and overall effort (for example, cost, time, resources). A set of attainable and agreed upon recommendations were then assembled to form the SSI Improvement Bundle for GYN surgery. Many of the pre-, intra-, and postop team members remained involved with the project to lead the planning and implementation of these ideas. They were engaged in the process because of their involvement during the planning phase and possessed the necessary expertise and skills to support the identified improvements.

SSI Improvement Process 

Description of the QI Activity

Team Assembled and Project Implemented

The large multidisciplinary team was assembled for a kick-off meeting on October 21, 2011. Risk factors throughout each phase of the surgical episode were identified and subteams were created to address these opportunities. Implementation of the project began on March 1, 2012, with a goal to reduce the occurrence of SSI by 50 percent.

Project Implemented 

Resources Used and Skills Needed

Three separate teams were involved in the GYN SSI Project, encompassing the predefined phases of the surgical episode. Each team was comprised of 8–11 members and included representation from physicians (gynecologic surgeons and anesthesiologists), residents, nurse practitioners, nurse ,managers, infection prevention, a quality director and a QI Project Manager. The SCR provided data support and guidance around variables/definitions associated with data collection. Leveraging the strengths of the individual contributors allowed team members to focus on what they do best, which ultimately sustained engagement in the project.

Minimal costs were added through the improvement efforts. They included the procurement and distribution of antibacterial soap for preoperative skin cleansing and the use of Sage® CHG wipes.

What Were the Results?

Overall Results

The ACS NSQIP 30-day postoperative occurrence summary data as well as the case detail report was reviewed on a quarterly basis and shared during staff and team meetings. The Semiannual Report from January 1, 2011, through December 31, 2011, continued to demonstrate high SSI rates (2.85 percent observed/2.09 percent expected). Interventions were not yet implemented during this time period. The most recent Semiannual Report from July 1, 2011, through June 30, 2012, showed significant improvement in a short period of time (1.43 percent observed/2.02 percent expected). These results corresponded to the second decile.

Gynecology SSI Risk Adjusted Data 


While there were challenges during the process, no prolonged setbacks were identified. Initially there was a recurring issue with trainee compliance with standard postop orders. By incorporating this information into standing trainee education and ongoing feedback and reinforcement by GYN staff and inpatient nursing, this was successfully addressed.

Surgical draping also provided another challenge. Adherence to the new method of patient draping in the operating room was initially problematic, however, this was resolved by ensuring trainees were educated on the proper draping technique as well as by providing consistent feedback.

Tips for Others

Obtaining the support of key leadership is critical to the success of any endeavor and cannot be overemphasized. Once this has been accomplished, using a multidisciplinary approach to identify opportunities for improvement increases the success of any initiative. Regular communication of challenges and accomplishments was vital in order to maintain engagement.

The division of work into three separate areas proved to be invaluable. A team lead was assigned for each and the team members had the expertise and the ability to focus on specific elements within their domain. This approach helped the overall project move forward more quickly and developed better outcomes related to improvement opportunities. During this time the QIO (project leader) provided regular updates to the Women’s Health Institute chair and other key stakeholders, including medical and nursing staff.

Cleveland Clinic strives to put “Patients First.” Reducing SSI is an example of how this can be achieved through communication, collaboration and commitment.


  1. Scott II RD. The Director Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Centers for Disease Control and Prevention 2009.
  2. Anna R. Gagliardi, PhD, Darlene Fenech, MD, Cagla Eskicioglu, MD, Avery B. Nathens, MD, Robin McLeod, MD. Factors influencing antibiotic prophylaxis for surgical site infection prevention in general surgery: a review of the literature. Can J Surg, Vol. 52, No. 6, December 2009.
  3. Virginia Leigh Lipke, RN, MHA, ACRN, CIC, Anthony S. Hoytt, MHA. Reducing Surgical Site Infection by Bundling Multiple Risk Reduction Strategies and Active Surveillance. AORN Journal Vol. 92 No. 3, September 2010.
  4. Jonah J. Stulberg, MD, PhD, MPH, Conor P. Delaney, MD, PhD, Duncan V. Ncuhauswer, PhD, David C. Aron, MD, MS, Pingfu Fu, PhD, Siran M. Koroukian, PhD. Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections. Downloaded from at Columbia University, June 24, 2011.


Cleveland Clinic
Cleveland, OH
SCR: Nancy Anzlovar, RN, BSN
Surgeon Champion: Allan Siperstein, MD, FACS
Dominique LaRochelle, MHA
Janice SanMarco, RN, BSN, MBA
Mehdi Moslemi-Kebria, MD