Data to drive improvement in Surgical Site Infection

Ms Robyn Austin1,2

1Mid North Coast Local Health District, Port Macquarie, Australia,
2Agency of Clinical Innovations, Chatswood, Australia


Mid North Coast Local Health District (MNCLHD) in NSW had two of its major rural hospitals selected to undertake the Australian pilot of the National Surgical Quality Improvement Program (NSQIP), as they were dedicated to improving the quality and safety of their patient’s care during their surgical journey.

NSQIP requires an appointed surveillance officer to collect clinical data on surgical patients with direct patient follow up 30days post operation. This data is risk-adjusted, benchmarked and compared with peer hospitals nationally and internationally on surgical outcomes. Outliers are identified and reports provided to the surgical services. Armed with this information targeted improvement projects are implemented using quality improvement methodologies.


Analysis of reports from NSQIP provided the surgical services with validated surveillance data highlighting that the MNCLHD was an outlier for surgical site infections (SSI). With this knowledge, clinicians felt empowered and engaged to embrace the recommended practices to improve patient care.

Clinical Practice Improvement (CPI) methodologies were used to develop a “bundle” of best practice recommendations looking at system-based practices and processes, with the aim to reduce clinical practice variations across the district.


In one facility, with the implementation of the recommendations and empowering the clinicians to engage in discussions about processes, the rate of SSI for colorectal Surgery was consistently seen to be reducing.


Having robust, risk adjusted and benchmarked clinical data empowers and engages clinicians to review their systems-based practices and clinical variations and adopt recommended practices to improve the surgical care of their patients.


Registered Nurse with perioperative nursing background. Commenced as Surgical Clinical Reviewer for American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) in 2016. Qualified surveillance officer to collect clinical data on surgical patients to identify targeted improvement projects. Use of Clinical Practice Improvement methodologies to implement system-based practice changes identified through data results.

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