Hospital Leadership’s Crucial Role in Sepsis Surveillance: Success at Phoebe Putney Health System

By Cynthia Chaney, BSN, FNP

Through the ongoing transition to value-based care, hospitals are facing increasing pressure to not only revamp their practices but also to report on these changes to standardize the quality of care. Some of these quality initiatives, like sepsis management, are now directly tied to financial performance and incentives. Recently, the Centers for Medicare and Medicaid Services (CMS) introduced the Severe Sepsis and Septic Shock: Management Bundle (SEP-1) as part of their quality reporting program, making sepsis patient management a focal point for improving both patient care and financial outcomes.

The leadership team at Phoebe Putney Health System recognized a pressing need to enhance real-time point-of-care adherence to sepsis care protocols and ensure the timely continuity of care for sepsis patients. With CMS’ recent decision to integrate SEP-1 into value-based payment models, Phoebe Putney’s proactive improvements in our sepsis program, driven by hospital leadership, are positioning the hospital for success.

The link between sepsis and quality improvement for value-based care

As a quality measure, SEP-1 establishes time-sensitive treatment protocols for clinicians that focus on early sepsis recognition and intervention to improve patient outcomes. The emphasis on early treatment is critically important; each hour of delayed treatment increases the risk of mortality for patients with sepsis by about 8%.

In August 2023, CMS announced the new inclusion of a SEP-1 performance score to calculate value-based performance bonuses or penalties beginning in FY 2026 (October 1, 2025) using data from the 2024 performance period. SEP-1 will now be part of VBP’s Safety Domain, which accounts for 25% of a hospital’s total performance score for the program.

While hospitals have been reporting SEP-1 performance for years, its inclusion in Value-Based Purchasing introduces direct financial consequences and opportunities based on performance levels. Beginning in January 2024, SEP-1 performance will be used to determine value-based care payment adjustments.

For our hospital, this was a wake-up call to better integrate and optimize our existing sepsis program. With very clear C-suite support for sepsis quality improvement, we set out to optimize our current technology and workflow while maintaining heightened SEP-1 compliance across our hospital.

Prioritizing sepsis surveillance at Phoebe

Phoebe Putney Memorial Hospital serves approximately 65,000 patients per year in the emergency department, and has over 400 inpatient beds, with a quickly expanding ICU. We began with a focus on identifying and treating sepsis cases efficiently, particularly in the emergency department, while ensuring SEP-1 steps were consistently followed throughout the patient’s care journey. To accomplish this change, we hired a sepsis coordinator and introduced technology from Wolters Kluwer Health to enhance sepsis case identification and tracking.

While on paper we had the individual pieces needed for a successful sepsis monitoring and treatment program, it took dramatic cultural change spurred by the laser focus of new leadership to see a dramatic improvement in our sepsis protocols.

Optimizing team collaboration and sepsis management workflows

With new leadership at the helm, our team took a candid look at our sepsis performance across departments to identify opportunities for improvement. After this analysis, we focused on the emergency department and patients moving into the ICU, as SEP-1 steps were often missed or delayed due to these care transitions.

With frontline clinical teams already under immense pressure, we turned to a sepsis surveillance solution that integrates with the EHR to monitor for sepsis risk in the background and send reminders when SEP-1 steps were in danger of being missed. Continuous automated surveillance of vital signs, lab results, care team assessments, and clinical documentation using clinical Natural Language Processing (cNLP) is key for achieving accurate user-friendly integration. With the technology in place, we completed extensive staff training on the technology platform and explored the best way to alert frontline staff amid their already busy workflow. In addition to charge nurses receiving SEP-1 intervention alerts through their Vocera badges, we also decided to incorporate virtual nurses who could augment on-site staff to ensure no alerts are missed.

Through thoughtful workflow changes, we received support from nurses, managers, pharmacy, and hospital leadership, which enabled our program’s success. Building on the involvement of the CEO at Phoebe Putney Memorial Hospital, we held weekly safety huddles, immediately followed by a sepsis huddle to ensure alignment across the program.

Realized improvement in compliance and care outcomes

Studies show improvement in SEP-1 compliance has a significant downstream positive impact on length of stay, readmission rates, and patient mortality. The biggest contributor to our success was the focused leadership provided—there was a deep emphasis on the best way to use our resources, and the CEO was quick to encourage teams and educate them on the systems we put in place.

Before incorporating a sepsis surveillance solution, our compliance goal was 60%, with inconsistent performance across the various SEP-1 bundle components. However, through a blend of sepsis surveillance technology, a supportive leadership team and collaboration with Wolters Kluwer, we achieved impressive improvement in SEP-1 compliance rates.

This summer, our bundled compliance scores for both the 3-hour and 6-hour bundles were over 90%. We have also seen positive shifts in trailing indicator metrics, such as mortality rates and length of stay as an organization, thanks in part to our focus on sepsis care.

Hospitals can’t delay sepsis

The very reason sepsis is so complex to treat appropriately—and SEP-1 compliance is so difficult to maintain—is because of the urgency required to quickly identify sepsis and follow specific steps in care. Hospitals must embrace this same urgency when evaluating and improving their sepsis management programs to prepare for the 2024 reporting cycle. Hospital leadership can play a pivotal role in prioritizing resources to support sustained sepsis care quality improvement. By combining this top-down accountability, integrated technology, and a thoughtful workflow, hospitals can reimagine their sepsis programs to improve and sustain compliance, and ultimately deliver better patient care.

Cynthia Chaney, BSN, FNP, is the Director of Quality Improvement, Accreditation and Infection Prevention at Phoebe Putney Memorial Hospital, where she has worked for nearly a decade in a variety of roles, including as an Advanced Practice Nurse. Throughout her career, Cheney has held leadership roles in clinician education and business development and has successfully managed diverse areas including inpatient and outpatient care.