PE R IOPE RAT IVE PRACT ICE


it needs to be a fully holistic approach and not just looking at the ‘hole in the patient’. She re-iterated the importance of assessing the hydration and nutrition of the patient, as well as their social circumstances. Dressings are important medical devices and she explained that choosing the right dressing for the right wound, is an important aspect of perioperative care. Victoria went through different categories of dressings and how they can or should be used. It is a topic which needs some concentration and learning, and she suggests that wound care company representatives are happy to educate users on the finer points of use, so that the correct dressing is selected for the patient. Without a doubt, perioperative practitioners and junior surgeons have a lot to learn in this regard. The next speaker was Penny Smalley who gave a comprehensive presentation on the current state of knowledge on surgical plume. A future article will be devoted to this topic. There was a short session on the


OneTogether resources that have been developed and are available to download, given by Tracey Radliffe, one of the OneTogether team. They are accessible from https://www.onetogether.org.uk/ resources, and include decision guides, quality improvement resources, and posters on difference aspects of best practice to reduce SSIs. The next resource, which is in development at present, is focused on incision management and will be available in the spring next year.


The final speaker of the day was Professor


Jennie Wilson, president of the Infection Prevention Society and a member of the


Ten challenges to improving quality


1 Convincing people there is a problem 2 Convincing people that the solution chosen is the right one


3 Getting data collection and monitoring systems right


4 Excess ambitions and ‘projectness’ 5 The organisational context, culture and capacities


6 Tribalism and lack of staff engagement


7 Leadership 8 Balancing carrots and sticks – harnessing commitment through incentives and potential sanctions


9 Securing sustainability 10 Considering the side effects of change


Source: Dixon-Woods, M, and Martin, G. (2016) Table 1 JANUARY 2022


Many of the elements of change are about the socio-environmental actors, the culture in the team and the human factors in leadership of the change. Change needs consensus in the team. Therefore, it is important to involve and empower all the different stakeholders, so that their ideas are part of the solution – ensuring there is buy-in at an early stage in the process.


OneTogether Team. She gave a thoughtful and excellent session on making change in the workplace and why it is difficult to make it happen. She related many of her examples to the work which has been done at the John Radcliffe Hospital in Oxford, in neurosurgery, as described earlier by Dr. Halliday. She described how many of the elements of change are about the socio-environmental actors, the culture in the team and the human factors in leadership of the change. Change needs consensus in the team. Therefore, it is important to involve and empower all the different stakeholders, so that their ideas are part of the solution – ensuring there is buy-in at an early stage in the process. Often there is a great degree of variability and despite everyone knowing approximately what they should do, they all do it slightly differently. Few people read, remember and practice the policies as they are written, and the team needs to agree and sign up to the standards they aspire to practice.


Once those standards have been agreed, then it is possible to audit and action best practice. It is also essential that the ‘how’ of what we need to do is highlighted and the ‘who’ is responsible for it is clarified. Data is vital and measurement of progress – and also success – is equally important. To reduce SSI, prevalence requires many different changes and they are complex, with many varied members of the perioperative team involved from pre-assessment to discharge. A variety of stakeholders need to be involved in the changes, therefore. As the OneTogether Assessment Toolkit describes, many changes need to happen, each making a small change to deliver an overall reduction in SSIs. There is also a need within the planning process to ensure that the change is sustainable – sometimes this can be linked in at the planning stage; others need to be part of the continuing PDSA (Plan, Do, Study, Act) cycles to tweak the change and make sure it endures. One way that we frequently approach change is to imagine that we have the solution before we really know what the problem is. It is important, at the very


outset, to involve the stakeholders to define the issues. It is important to review the influencers – who may be outside the operating rooms, but have power and influence to assist with the changes that the team identifies. A very helpful paper on change management is that by Mary Dixon Woods, who highlights the challenges to improving quality.3


Ten challenges are


outlined, which consistently emerge. The paper is full of healthcare examples and practical solutions to help achieve successful quality improvement and provides a very helpful framework for delivering change. (See table 1)


Conclusion


One of the many elements of the change process is that it needs time; often a difficult thing to find, especially with such complex change as is required for the reduction of SSIs. The challenges listed are significant and, if cognisance is taken of them, will assist in mitigating some of the teamwork and leadership challenges. The study of human factors, which create the culture in which we function, is also extremely helpful to ensuring sustainable change and especially with the complexities of SSI reduction. The OneTogether toolkits and decision guides are extremely helpful to teams needing to instigate changes to their perioperative practice to manage their infection rates. It is to be hoped that the National Wound Care Strategy – when it is published will incorporate many of the elements of the OneTogether Quality Improvement resources.


Resources 1 Guest JF, Ayoub N, McIlwraith T, et al, Health eco- nomic burden that wounds impose on the National Health Service in the UK, BMJ Open, (2015); 5:e009283. doi: 10.1136/bmjopen-2015-009283


2 OneTogether Resources Accessed at https://www. onetogether.org.uk/resources/


3 Dixon-Woods M. & Martin G, Does quality improve- ment improve quality? Future Healthcare Journal, October 2016. https://www.rcpjournals.org/content/ futurehosp/3/3/191


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