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CPEL Initiatives Improve Sepsis Core Measure Compliance

The Certified Process Excellence Leader (CPEL) program at Kettering Health Network aims to empower employees to continue improving processes. Since its inception, the program has helped the network implement innovative ways to make improvements. A recent initiative of the CPEL program significantly improved Sepsis Core Measure compliance.

CPEL project manager: Leeana Weiss, PA-C, physician assistant at Soin Medical Center in the General Surgery and Trauma department. Weiss has worked at Kettering Health Network for about eight years. She designed and finished this CPEL project to complement her recent completion of her Master’s in Business Administration with a concentration in Healthcare Management.

Background: According to the Centers for Medicare and Medicaid (CMS), sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency that, without timely treatment, can rapidly lead to tissue damage, organ failure, and possibly death. Not only is sepsis devastating to patients and families, but it also demands significant hospital resources and costs the health care industry more than $24 billion each year.

Because of the staggering impact sepsis has on patients, loved ones, and health systems, CMS responded with the Sepsis Core Measure, a bundle of evidence-based process measures. Evidence shows that better adherence to these measures results in a reduction of morbidity in the sepsis patient population.

Objective: At the start of the project, Soin Medical Center met the Sepsis Core Measure bundle 36.84% of the time, compared to a target of 58% or higher. This resulted in decreased revenue from CMS and increased patient complications.

The goal was to decrease the number of fall-outs for tissue perfusion assessment in the Sepsis Core Measure at Soin Medical Center from 2.67 per month to 1.3 per month.

Method: With the support of Erica Schneider, vice president of Patient Care at Soin Medical Center; and Frank Farkash, director of Clinical Quality; Weiss led a multidisciplinary team through the CPEL program. Her team included Alyssa Gans, MD, director of the Intensive Care Unit; Lisa Galloway, ICU nurse manager; Lisa Edwards, ICU educator; and additional ICU nursing staff and Epic analysts.

Weiss led her team through a Value Stream Analysis to pinpoint the part of the process where they should focus their efforts. This allows leaders to easily see where the highest priority of change effort should occur to achieve maximum results.

The team determined that the focus should be on the fall-out for these sepsis patients, as the Sepsis Core Measure bundle was not easy to follow. Thus, the Rapid Improvement Event focused on a provider template to more easily guide providers through the Sepsis Core Measure process.

Results:  At the time of the project’s completion, Soin Medical Center achieved the compliance goal, with consecutive months of zero fall-outs.

March 20, 2020
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