Effective surgical infection prevention and harm reduction require redesigning systems with safety in mind. The fundamental law of improvement is this: every system is perfectly designed to achieve exactly the results it gets. In order to attain a new level of performance in safety, there must be a new system. This applies to all forms of performance — such as selection, timing, and duration of antimicrobial prophylaxis; thermoregulation; oxygen tension; glucose control; hair removal and other basic prevention strategies.

Many health care organizations have used the Model for Improvement,* developed by Associates in Process Improvement, and have succeeded in creating new and safer systems for Surgical Site Infections. Using the key elements of the model, especially testing changes on a small scale with Plan-Do-Study-Act (PDSA)** cycles in all four areas, has helped organizations reduce harm from medications in their organizations by as much as 50 percent.

It is essential that surgical site infection reduction efforts are led by a multidisciplinary core team. Forming the Team

	Setting Aims Commitment to reducing surgical site infections is reflected by a strong and well-worded aim statement.
	Establishing Measures Improvement in outcome measures reflects the health status of the patient, whereas process measures reflect the care delivery to the patient. Improvement in outcome measures has a direct effect on mortality and morbidity.
	Selecting Changes Teams must test and implement changes in order to reduce surgical site infections. These include use of antibiotics; perioperative normothermia, glucose and oxygen; and shaving of the operative site.
	Testing Changes Testing changes to care processes must be done carefully so as not to add additional error and harm to the system. Use PDSA cycles to test changes on a small scale before implementing them broadly.