This measure tells teams how often every element included in the Severe Sepsis Bundles was completed in each patient during the review period. It is defined as the percent of cases of severe sepsis and/or septic shock for whom all applicable Severe Sepsis Bundles elements are completed.
Measures of reliability inform teams about the extent of error-free operation of their clinical processes. In this case, not following every indicated bundle element in each patient with severe sepsis and/or septic shock constitutes an error.
Note: A strongly suggested goal for compliance is 95 percent. If the reliability measure is less than 95 percent in any given month, teams should identify which specific bundle elements are not being reliably executed. Once these specific elements are identified, teams can improve their performance on this measure in the next cycle by addressing the underlying obstacles to reliably implementing these bundle elements.
Numerator: The number of cases of severe sepsis and/or septic shock that completed all applicable Severe Sepsis Bundles elements
Denominator: The total number of patients with severe sepsis and/or septic shock
Exclusion: Non-severe sepsis
Increase the number of cases completing the Severe Sepsis Bundles to 100 percent.
Data Collection Plan
Data may be collected concurrently — that is, once a patient is placed on the hospital’s severe sepsis protocol, data can be abstracted from the patient chart in real time — or retrospectively using a chart review, a method generally recommended for more experienced improvement teams.