When LeWanza Harris, MD, chief quality officer of Atlanta-based Emory Healthcare, dug deeper into the system’s sepsis data last year, the metrics told a story of fragmentation across the system’s 11 hospitals.
“The performance was inconsistent and in places low,” Dr. Harris said in an upcoming episode of “Becker’s Clinical Leadership Podcast.”
There was significant spread where one hospital site was performing at 85% compliance with the SEP-1 bundle. Another, running on the same EHR and under the same policies, was at 30%. Early on, some sites measured in the teens.
Rather than starting with staff training, Dr. Harris and the sepsis committee took a step back to map out where the underlying workflows were breaking down.
A review of front-line operations found several problems. Sepsis alerts in the EHR were frequently underused or ineffective, so clinicians regularly deferred them. Blood culture collection lagged, and fluid assessments were done manually. In many cases, a clinician recognized sepsis before the alert fired — a sign the technology was trailing clinical judgment instead of supporting it.
Recognizing that these challenges tied back to governance and workflow reliability, Dr. Harris and her team created a systemwide sepsis steering committee last October to set enterprise targets and escalation pathways, with executive sponsors who met monthly with process owners to clear barriers rather than simply receive updates. Underneath it, structured unit-level case review drove the work locally.
The team also brought clinical documentation integrity staff into front-line sepsis work alongside quality team members to reduce preventable documentation failures and clarify how organ dysfunction and rule-outs get captured in the patient record.
“A patient can receive flawless care and still fail to measure because the note lacked one phrase, and that gap was real and it was fixable,” Dr. Harris said.
That same logic drove the decision to align SEP-1, the CMS sepsis care bundle measure that covers all patient encounters, with PSI 13, the postoperative sepsis patient safety indicator that covers a subset of elective surgical cases. While SEP-1 performance depends on the care timeline, PSI 13 is heavily coding-driven. Previously, clinicians were tasked with trying to satisfy two disconnected sets of expectations from a single patient note. Now, sepsis program managers, the CDI team, quality abstractors, surgical quality and physician leadership work as one cross-functional group focused on improving performance on both measures.
Order sets were another source of hidden variation. Emory had accumulated seven separate sepsis order sets over time, each built for a legitimate local need, but collectively they left clinicians guessing which one to use and were often missing bundle elements. The team consolidated them into a single order set with setting-specific versions for the emergency department, inpatient units and the rapid response team.
On the technology side, the team deliberately constrained its build to existing tools in Epic’s Foundation System, with no custom development. That included a sepsis timer, a sepsis navigator giving a single view of the bundle, a nursing documentation tool, a predictive model for early detection, automated lactate and antibiotic timers, and a fluid reassessment form.
“The alert refinement and duplicate order reduction was treated as first-class work, not cleanup,” Dr. Harris added. “Reducing noise was as important as adding the right signal.”
The results have been substantial. Systemwide SEP-1 bundle compliance rose from roughly 32% in March 2025 to nearly 60% in recent data — approaching the national average of 63% — and Emory expects to exceed its systemwide goal of 43% for fiscal year 2026.
“To be able to accomplish it within a year really speaks to the redesign of our systems and our processes, and the work that the front-line team has done,” Dr. Harris said.
Sustainment is now treated as its own phase of the work, with monthly performance reviews, real-time dashboards, structured case review and unit-level scorecards.
“The measure of success shifted from did we implement it to does it hold on a night shift in August,” Dr. Harris said.
Beyond the numbers, Dr. Harris pointed to a cultural shift: closer collaboration among quality, surgical and documentation teams that didn’t previously work together, and a growing sense of ownership among front-line staff.
Asked what she’d tell other quality leaders trying to replicate Emory’s progress with sepsis compliance, Dr. Harris distilled the effort into five lessons:
1. Start by examining variation in sepsis compliance, not the average, since the spread shows where the design is failing.
2. Decide who owns the work before building anything.
3. Consolidate order sets even though it costs political capital, because it returns reliability.
4. Bring documentation and coding staff in at the start rather than after results disappoint.
5. Make data local and visible, then close the loop by fixing what it shows.
“It is important that front-line staff and clinicians feel like they own the process, that they own the work themselves,” she said. “Having a shared sense of ownership is what really helped us to also move the needle.”
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