D226 Assessment Task 1: Enhancing Sterilization Protocols to Reduce SSIs

Grace J.
November 12, 2025November 12, 2025
BSN, D226, Western Governors University

Student Name

Western Governors University

D226 BSNU Capstone

Prof. Name

Date

What are Surgical Site Infections (SSIs) and why are they significant in healthcare?

Surgical Site Infections (SSIs) are infections that occur after surgery in the part of the body where the procedure took place. These infections may involve only the skin surface or extend deeper into tissues, organs, or implanted materials. SSIs are a major cause of morbidity, prolonged hospital stays, increased healthcare costs, and sometimes mortality. According to the Centers for Disease Control and Prevention (CDC), SSIs account for approximately 20% of all healthcare-associated infections in hospitalized patients (CDC, 2023). Their prevention and control are critical in ensuring patient safety, promoting faster recovery, and supporting value-based care models that focus on improving quality while reducing costs.

BSNU Capstone Course Task One: Healthcare Change Proposal

This paper represents Task One of the BSNU Capstone Course, focusing on the creation of a comprehensive healthcare change proposal. The purpose of this paper is to identify an organizational sponsor who will evaluate, support, and approve the proposed initiative. The document also includes sponsor feedback, supporting evidence, and a clear justification of how the change contributes to value-based care improvement.

Additionally, this proposal identifies essential stakeholders, outlines a strategic implementation plan, and concludes with a reflective discussion of the author’s leadership role and influence as a change agent in clinical transformation.

Organizational Context

The proposed change will be implemented at the Mike O’Callaghan Military Medical Center (MOMMC), a military treatment facility (MTF) managed by the Defense Health Agency (DHA) and the Department of Defense (DoD). Located at Nellis Air Force Base in Las Vegas, Nevada, MOMMC provides emergency and specialty medical services to active-duty service members, dependents, and DoD beneficiaries.

The author currently serves as a civilian contractor and registered nurse in MOMMC’s Emergency Department (ED). The ED consists of twenty beds and two trauma bays, with staffing composed of military personnel, civilian employees, and contractors.

Due to its Trauma Level III designation, MOMMC receives both military and civilian trauma cases. While staffing stability is generally strong, challenges arise during military deployments. Approximately 40% of the ED workforce comprises civilian and contract employees, ensuring continuous coverage during deployment rotations.

Change Proposal Description

Current Process

At present, patients entering the emergency department check in at a front desk staffed by two registration technicians. These staff members perform full patient registration before the patient undergoes triage or medical evaluation. This process, while administratively thorough, introduces delays for patients presenting with critical conditions such as chest pain or cardiac distress.

Proposed Change

The proposed modification involves relocating registration technicians to the back area of the department, where they will handle administrative and clerical responsibilities. In their place, a medical technician and a registered nurse (RN) will be stationed at the front desk to conduct rapid symptom assessment and quick registration.

This restructuring prioritizes clinical triage at the initial point of contact, ensuring that patients exhibiting ST-Segment Elevation Myocardial Infarction (STEMI) symptoms are identified and treated without delay.

Purpose of the Change

The primary goal of this proposal is to reduce the “door-to-EKG” time for patients exhibiting cardiac symptoms. According to the American Heart Association (AHA) and the American College of Cardiology (ACC), a 12-lead EKG should be obtained within 10 minutes of a patient’s arrival to the ED (Dechamps et al., 2016). Currently, MOMMC achieves this benchmark for only 40–60% of patients.

By placing medically trained professionals at the front desk, the emergency department can significantly improve early recognition and timely intervention, leading to improved patient survival rates and alignment with national cardiac care standards.

Impact of Proposed Change

Aspect	Current State	Proposed Change	Expected Outcome
Staffing at Front Desk	Two registration technicians	One medical technician and one registered nurse	Quicker symptom recognition and faster EKG administration
Door-to-EKG Time (STEMI Patients)	40–60% compliance with 10-minute standard	100% compliance with 10-minute benchmark	Improved clinical outcomes and compliance with AHA standards
Patient Flow	Delays during registration	Streamlined triage and registration	Reduced wait times and enhanced satisfaction
Role of Registration Technicians	Full registration	Administrative support at back desk	Better utilization of staff skills

This staffing redesign aligns clinical expertise with frontline patient needs, optimizing both efficiency and safety in emergency cardiac care.

Feedback from Organizational Sponsor

Brian Hubbard, RN, BSN, MPA, was selected as the organizational sponsor due to his background in intensive care, cardiac catheterization, and supervisory nursing roles at MOMMC. He offered practical recommendations emphasizing data-driven decision-making and adaptive leadership.

Mr. Hubbard endorsed the proposed staffing model and advised a 60–90-day pilot implementation before formal adoption. During the trial, nurses and medics may need to work 1–2 additional shifts per month, potentially encountering minor resistance. He stressed the need for transparent communication and staff engagement, highlighting the link between the proposed change and improved patient outcomes.

Potential Barriers and Strategies

Barrier	Description	Mitigation Strategy
Staff Resistance	Temporary workload increase and schedule adjustments	Foster open dialogue, involve staff in planning, and emphasize patient safety benefits
Administrative Resistance	Possible hesitancy from DoD or DHA to alter staffing models	Present outcome-based evidence and compliance with national cardiac guidelines
Skill Gaps	Staff may lack familiarity with rapid registration	Provide structured training and mentorship programs

Overcoming these barriers requires strong leadership and staff empowerment, ensuring all team members understand the long-term benefits of the new process.

Value-Based Care Enhancement

The proposal aligns directly with value-based care principles by enhancing clinical efficiency, patient safety, and satisfaction without increasing financial burden. Key improvements include:

Decreased door-to-EKG time for cardiac patients.
Improved early detection and management of critical conditions.
Enhanced interdisciplinary collaboration among nursing, medical, and administrative teams.
Higher patient throughput and satisfaction scores.

By optimizing staff placement and workflow, MOMMC can deliver higher-quality care while maintaining fiscal responsibility.

Key Stakeholders and Collaboration

Stakeholder	Role in Implementation
Staff Nurses and Medics	Conduct rapid triage and EKGs
Registration Technicians	Manage back-end administrative functions
Emergency Room Nurse Manager	Supervise workflow and staffing
Emergency Department Medical Director	Provide clinical governance
Registration Director	Oversee registration processes
Chief Nurse	Support policy alignment and resource allocation
Hospital Commander	Endorse organizational support
Staffing Chief	Approve and formalize staffing adjustments

Regular monthly progress meetings will be scheduled to review Genesis charting system data, focusing on metrics such as door-to-EKG times, patient length of stay, and satisfaction indicators.

Resources and Cost Considerations

The initiative primarily utilizes existing internal resources without requiring new financial investment. Military personnel salaries are not hourly-based, meaning that temporary workload redistribution does not affect payroll expenses. The main resource investment involves training, data tracking, and staff engagement sessions—all achievable within the current operational structure.

Implementation Plan

Phase	Description
Planning	Engage stakeholders, finalize logistics, and outline trial parameters
Milestones	Track weekly and monthly data for door-to-EKG times
Implementation	Train staff and initiate rapid registration pilot
Evaluation	Conduct 90-day review and assess success metrics

Continuous evaluation will be supported by data-driven monitoring to ensure sustained improvement and guide long-term staffing policy changes.

Expected Outcomes

Outcome	Description
100% Compliance	All eligible patients receive EKGs within 10 minutes
Improved Patient Outcomes	Faster interventions reduce cardiac complications
Increased Patient Satisfaction	Reduced wait times improve overall experience
Financial Benefits	Enhanced throughput increases service utilization
Accreditation Maintenance	Sustained compliance with AHA and DoD standards

These results not only elevate patient care but also uphold ethical nursing principles of nonmaleficence and fidelity, ensuring patients receive prompt, safe, and effective treatment.

Use of Technology

The Genesis Electronic Health Record (EHR) system will serve as the primary tool for tracking performance data. This system facilitates real-time analysis of patient flow, EKG completion times, and triage efficiency. Data visualization dashboards can also be developed for leadership review, fostering a culture of transparency and accountability.

Measuring Success

Success will be determined by both quantitative and qualitative indicators, including:

Continuous improvement in performance metrics.
Positive patient satisfaction survey results.
Enhanced staff morale and adoption of new workflows.

Sustained engagement and communication will ensure that improvements are maintained and celebrated within the organization.

Reflection on Change Agent Role

As a veteran emergency nurse with over two decades of experience, the author has observed systemic inefficiencies that delay patient care. By leveraging evidence-based practice, leadership skills, and interdisciplinary collaboration, the author fulfills the role of a change agent committed to advancing healthcare outcomes. Through advocacy, education, and data-supported reasoning, the author fosters a culture of continuous quality improvement within the emergency care setting.

Potential for Broader Application

If proven effective, this rapid registration and triage model can be replicated across other military treatment facilities (MTFs) nationwide. Implementation across the DoD healthcare system could improve response times, reduce cardiac-related mortality, and enhance operational readiness in both military and civilian patient populations.

References

Butt, T. S., Bashtawi, E., Bououn, B., Wagley, B., Albarrak, B., Sergani, H. E., Mujtaba, S. I., & Buraiki, J. (2020). Door-to-balloon time in the treatment of ST segment elevation myocardial infarction in a tertiary care center in Saudi Arabia. Annals of Saudi Medicine, 40(4), 281–289. https://doi.org/10.5144/0256-4947.2020.281

Centers for Disease Control and Prevention. (2023). Healthcare-associated infections: Surgical site infections (SSI). https://www.cdc.gov/hai/ssi/