PSQH Innovation Awards Winner: St. Bernard Hospital Improves Sepsis Care and Reduces Mortality Rates

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By Jay Kumar

Editor’s note: The seventh annual PSQH Innovation Awards recognize healthcare organizations who overcame patient safety or quality improvement challenges. In this article, we highlight the winning submission from St. Bernard Hospital in Chicago.

The challenge

In St. Bernard’s submission, Joanne Igney, Director of Quality, wrote that sepsis care was a multifaceted challenge rooted in both internal resistance and the complexity of sepsis care compliance. Despite overwhelming evidence supporting the Centers for Medicare & Medicaid Services (CMS) sepsis bundle, both administrators and providers resisted its standardized application, Igney wrote. The compliance requirements often faced skepticism from key stakeholders, who questioned the one-size-fits-all care model.

“Providers, accustomed to their own clinical judgment and decision-making processes, found the mandated guidelines restrictive,” she wrote. “Physicians were particularly reluctant to adopt a standardized approach, while nurses feared calling Code Sepsis without certainty about meeting the clinical criteria.”

The core challenge was not only compliance but changing a deeply ingrained culture where the perception of rigidity in sepsis treatment had to be replaced with a more systematic, evidence-driven approach. As a result, St. Bernard developed a structured, empathetic solution was developed to acknowledge the frustrations of healthcare teams while aligning with the goal of better sepsis outcomes, wrote Igney.

“Breaking down the implementation barriers through continuous, multi-pronged communication helps engage the organization through data-driven discussions, fosters a collaborative environment that allows stakeholders to voice their concerns, while also encouraging them to take ownership of the process. It was through this iterative, respectful approach that we began to see the tide turn,” she added.

Organizational resistance and the gaps in compliance help focus on creating awareness and commitment at every level. This was a gradual process requiring a strong foundation of education, communication, and continuous improvement. The guiding principle was to first perfect critical steps before expanding the focus to tackle other gaps.

According to Igney, the key components were:

  • “THINK SEPSIS” Campaign: A pivotal initiative aimed at increasing awareness across all departments. It stressed the urgency of timely recognition and treatment of sepsis, emphasizing that “Sepsis is all about timing. ” The goal was to initiate the changes in the Emergency Department to ensure that no patient was overlooked in the early stages, where the first signs of sepsis often appear.
  • Education and training: Targeted educational seminars for both the Emergency Department and inpatient teams began. The curriculum was designed to highlight the importance of a standardized approach while acknowledging that mistakes occur during the learning phase. This strategy fostered an atmosphere of patience and support as staff members navigated the learning curve.
  • Empowering nurses: The most transformative aspect was the shift to a nurse-driven protocol for calling code sepsis. Nurses were empowered to independently initiate sepsis alerts, a practice shown to improve compliance rates in other hospitals. This empowerment encouraged nurses to act decisively, enhancing confidence and accelerating the process.
  • Celebrating successes: As the program rolled out, deliberate celebrations ensued every step forward, no matter how small. When nurses called code sepsis, even if the patient didn’t meet criteria, positive reinforcement was given. This bolstered morale and created an atmosphere of support rather than scrutiny.
  • Continuous feedback and iteration: Once one gap was addressed, we moved to the next, applying the same methodical approach to identify areas for further improvement. This iterative process helped build a culture of continuous learning and refinement, essential for sustaining the effort long-term.

The solution

A multidisciplinary team of stakeholders drove this project, each contributing to its success, wrote Igney. The stakeholders included:

  • Quality improvement team: Spearheaded the initiative by providing evidence of existing gaps and the need for urgent action. They presented statistical data that demonstrated the inadequacies of the current system, ensuring that every team member understood the necessity of change.
  • Leadership and board members: The Administration played a crucial role in endorsing and championing the project. Their support ensured that the initiative had the organizational backing needed for resources, time, and effort. Senior leaders also modeled the behavior they wanted to see from frontline staff, signaling that sepsis care was a top priority.
  • Physicians and key providers: A core group of influential physicians became change agents, helping to spread the message and advocate for new protocols. Their buy-in was critical in getting the rest of the medical staff on board.
  • Nursing and Respiratory teams: Nurses were at the forefront of implementation, and their role in calling code sepsis was central to the success of the initiative. Respiratory therapists contributed by providing timely lab results, such as lactic acid levels, which allowed for more immediate interventions.
  • Pharmacy team: Collaborated with medical staff to ensure sepsis bundle compliance by modifying protocols and adjusting medication administration as necessary.
  • IT and Case Management: The IT department played a key role in updating order sets and streamlining the process, while Case Management and Health Information Management worked together to address documentation gaps, a critical issue that had been identified during the data validation process.
  • Laboratory team: Worked closely to establish critical thresholds for monitoring sepsis biomarkers, ensuring that any critical lab result triggered timely follow-up and intervention.
  • Patient and Family Engagement: Feedback from patients and families was crucial for improving both patient education and post-discharge care. Understanding the patient experience allowed us to refine our education materials and strategies to reduce the likelihood of readmissions.

The implementation of this solution was a structured yet adaptive process:

  • Gap analysis: The hospital began by identifying where the system was falling short. This involved reviewing sepsis compliance data and speaking with providers and staff to understand where the bottlenecks were.
  • Leadership buy-in: We communicated the need for change to leadership, helping them understand that the status quo was unacceptable and that CMS penalties and poor patient outcomes were driving the need for action.
  • Multidisciplinary collaboration: St. Bernard engaged all relevant teams—from physicians to IT specialists—to collaborate on finding practical solutions and ensuring everyone was on the same page.
  • Education: The hospital rolled out training sessions tailored to different staff roles, focusing on improving knowledge and comfort with the new protocols.
  • Continuous monitoring: After implementation, we kept the momentum going by providing frequent updates, reviewing compliance rates, and offering continued support.
  • Celebrating wins: Recognition of successes, whether big or small, was a key component in maintaining engagement and momentum.

The solution’s impact

The results were clear and impactful, Igney wrote, including the following:

  • Increased compliance: Sepsis bundle compliance rates steadily increased month-over-month, reflecting the effectiveness of the initiative and the buy-in from staff.
  • Improved provider confidence: As providers and staff became more familiar with the protocols, their confidence in delivering sepsis care grew significantly.
  • Decreased mortality rates: Most importantly, the sepsis mortality rate dropped dramatically, from 22% to 8%, surpassing the goal of 10%. This was a direct result of timely interventions, more accurate diagnoses, and better coordination of care.

One of the biggest challenges was the CMS data validation process, which initially uncovered gaps in documentation. Failing the first validation presented a significant setback, but it also provided valuable insights into where improvements were needed. St. Bernard addressed this by:

  • Revising order sets to ensure clarity on sepsis diagnosis and treatment protocols.
  • Re-educating staff on proper documentation practices, including ensuring medication and volume administration were clearly noted.
  • Implementing systems to automatically alert providers when repeat tests, like lactic acid levels, were needed.

By addressing these challenges head-on, the hospital successfully passed the subsequent CMS validation and maintained continuous improvements in both process and outcomes.

The implemented changes have continued to evolve. The “THINK SEPSIS” campaign has had lasting effects on the entire organization, with sustained commitment from leadership, even amid staff turnover. As part of our ongoing efforts, a Sepsis Coordinator role was created to ensure that the processes we established continue to evolve and remain effective.

“Healthcare organizations often face significant challenges when attempting to implement large-scale change, especially with sepsis care, which is complex and time-sensitive,” Igney wrote. “Our journey underscores the importance of collaboration, perseverance, and patience. While CMS standards may seem daunting, our experience proves that structured, evidence-based strategies can reduce mortality and improve patient outcomes. The broader community can learn from our approach to empower frontline staff, engage stakeholders, and celebrate small wins to achieve lasting change.”

Supporting materials include:

  • Nurse-driven protocols for ordering sepsis labs.
  • Code Sepsis overhead pages for real-time alerts.
  • Modified order sets for three-hour and six-hour sepsis bundles.
  • A timeline tool for tracking sepsis care across various stages of treatment.
  • Real-time lactic acid monitoring to alert providers to critical values.
  • Mortality rates trend:

– 2021 – 21%

– 2022 – 22%

– 2023 – 14%

– 2024 – 8% (meeting the goal of less than 10%)

“This comprehensive approach should not only demonstrate the effectiveness of the solution but also showcase the collaborative effort, persistence, and measurable impact,” according to Igney.

The sepsis organizational change followed a typical sepsis compliance rate presentation to the Hospital Board, as they first questioned the trending St. Bernard Hospital sepsis mortality rates and posed the challenge to reduce the sepsis mortality rate, she added.

“Regardless of our compliance rates, the ultimate test is saving lives,” Igney wrote. “By adhering to these standards and trusting the process, we achieved our ultimate goal—saving lives.”

Honorable mentions

The following submissions were selected as honorable mentions:

Geisinger, Danville, PA

The healthcare organization embarked on a groundbreaking journey to design a new multi-million-dollar tower within its existing hospital, with patient and staff safety highlighting much of Geisinger’s decision-making approach. Through an innovative and inclusive design process that engaged over 600 participants from across the organization and community, Geisinger created spaces that not only prioritize safety and functionality but also serve as dynamic environments for ongoing training and development.

Children’s Hospital Colorado, Aurora, CO

Children’s Hospital Colorado evaluated the quality of the independent double checks (IDC) routinely performed as part of high-alert medication administration to determine whether they were adding work without improving safety. Children’s evaluated the quality of IDCs in its pediatric intensive care unit (ICU) and cardiac ICU and at the same time, looked for opportunities for de-implementation of mandatory IDCs as a stronger mitigation than education and simulation. The hospital identified and prioritized medications for strategic removal of the IDC requirement using a scaled Plan-Do-Study-Act approach. Although certain high-alert medications will no longer require or prompt for an IDC, nurses are encouraged to request a double check if they deem it necessary based on their expertise.