Case Study: AHN Grove City 2026 Achievement Award

Excellence in Care Award | Small/Medium Division

Performance Improvement for Sepsis Bundle Compliance

The Goal

After several years of improvement, the hospital saw sepsis bundle compliance decline in 2024, signaling that earlier gains were not fully sustained. That change pointed to a need for stronger early detection, more consistent use of sepsis tools, and better follow-through on key treatment steps. The team focused on rebuilding a reliable process that kept sepsis awareness visible across clinical teams and supported timely care for patients.

The Intervention

Guided by root cause analysis and frontline feedback, the interdisciplinary sepsis workgroup strengthened the processes that support early recognition and timely treatment. Emergency department teams reinforced sepsis screening during triage, used a handoff tool to track key bundle steps, and reviewed performance through huddles, dashboards, and regular feedback.

The team also improved physician documentation, encouraged consistent use of sepsis order sets, and expanded education for clinical staff. Case reviews, one-on-one onboarding, Sepsis Awareness Month activities, and staff recognition kept sepsis visible throughout the year and reinforced consistent follow-through.

Results

The renewed focus led to a strong rebound in sepsis bundle compliance, reaching 85 percent year-to-date in 2025. Emergency department triage screening was completed for all patients with a clinical impression of sepsis, strengthening early detection at the point of entry. Readmissions also declined, and ongoing education, feedback, and frontline engagement helped build a more consistent culture of sepsis awareness across the hospital.

 

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Topics: Quality Initiatives

Revision Date: 8/17/2026

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