Change Package

Sepsis program development recommendations

Establishing an interdisciplinary sepsis program is key to successful bundle implementation and sustaining improvement in sepsis care and outcomes. The CDC Sepsis Core Elements provides a comprehensive framework for a successful sepsis program. Note that specific structures and functions will be unique according to local needs. The recommendations below are intended to supplement the CDC guidance.

Team structure

Include key stakeholders in the workgroup, such as pharmacists, education specialists, quality improvement specialists, data support, project managers, and front-line staff. Balance the need to include all relevant disciplines, care areas, and perspectives with the need to maintain a lean and flexible team structure.

See Figure 2 for an example of a basic sepsis team structure. For additional examples from IPSO hospitals, see Team Structure.

Education

Embed sepsis education into existing educational opportunities for all disciplines and establish a process for updating sepsis policies and procedures.

Education should empower all team members. Here are a few tips:

Educate staff on the valuable perspective parents and guardians bring to the team.
Focus on a culture of safety where all staff feel comfortable elevating concerns – empower staff to say “sepsis.”
Include physician trainees in the development and deployment of sepsis education. They are often among the first responding to a positive sepsis screen, so education must meet their needs.

For education resources, see Education.

Sustainability

Consider sustainability from the outset of program development and periodically when looking for new opportunities to cement learnings and further embed this work within your hospital’s structure. A sustainability planning worksheet can help. When planning for sustainability, make sure to align sepsis with organizational priorities, create enduring processes for front-line staff, and foster external partnerships.

Organizational prioritization

Consider early and often how sepsis work aligns with:

Hospital administrative requirements and achievements
- All-or-none bundle compliance
- Individual key process targets
Academic deliverables
- Research publications and presentations, national awards, grant receipts, etc.
Impact on other hospital strategic priorities
- Central line-associated bloodstream infections (CLABSI), escalation of care, transitions in care, microsystems, EHR optimization, equity work, etc.

Front-line structure and processes

Consider the following concepts in building sepsis structures and processes:

Integrate evolving evidence.
- Sepsis evidence is rapidly evolving; initial structures and processes will likely require adaptation over time. Develop a plan for ensuring new knowledge is properly evaluated and incorporated.
Integrate into data strategy.
- Table 4 shows data strategies to consider during program development.
- Consider developing local dashboards to track progress and drive improvement.

External partnerships

The IPSO collaborative model accelerated improvement by facilitating seamless sharing of knowledge and tools. Explore opportunities to collaborate with other hospitals and partner organizations early and often. Members of Children’s Hospital Association can participate in the Pediatric Sepsis Community of Practice, which facilitates collaborative knowledge-sharing and mutual learning to drive continuous improvement.

Table 4
Data and analytic strategy recommendations

	Description	Objectives
Data Governance	Decision-making about data and data assets	Operationalize framework of people, policy, process, and technology required to manage data assets Align this operationalization effort to key use cases tied to strategic initiatives/imperatives
Data Literacy	Ability to filter vast amounts of data and to read, understand, and communicate data as information	Foster analytics culture Build analytics competency and leadership in all roles Lead education/training efforts to improve data literacy
Analytics Tools (platforms)	Self-service analytics tools for the end user Graphical representation of information and data	Facilitate analytics tools access Establish best practices and guidelines for analytic tools Provide end-users with ability to perform queries, manipulate data, generate reports, and identify opportunities
Data & Analytics Operations (front door access)	Design mechanisms to request and access data Develop processes to support self-service analytics	Define workflows required to efficiently process data and analytics requests in accordance with data governance framework
Talent & Community	Data and analytics talent required to foster a Learning Healthcare System Analytics community to foster shared learning and growth	Align on core set of data and analytics roles — standardize job descriptions Develop a capability matrix for skill sets needed Identify current talent and gaps in current resources Develop succession plan framework

View chart.

Spread

After developing and optimizing a hospital sepsis program, organizations may consider spreading it to additional hospital care areas, system-wide practice, and community hospitals.

Spread ensures health equity, accelerates progress in care improvements, and enhances collaboration through a culture of learning (Jeffcott, S. et al, 2014). In the United States, an estimated 88.6% of pediatric hospitalizations occur in general hospitals rather than free-standing children’s hospitals (Freyleue et al, 2023). Because the recognition and treatment of sepsis is different for children, spreading pediatric sepsis improvement work to general or community hospitals is crucial to ensuring equitable care of children in all health care settings.

Spread is typically undertaken once outcomes and sustainability can be reliably demonstrated. The following resources provide important considerations, as well as detailed guidelines, when planning for spread of impactful improvement practices:

IHI Framework for Spread (Massoud et al, 2006) provides a structured approach to planning and launching the spread of improvement methods to ensure system-wide change.
Healthcare Improvement Scotland (Jeffcott, S. et al, 2014) outlines key factors for rapid and widespread implementation of effective improvement structures.

For examples of spread initiatives from IPSO hospitals, see Spread.

For citations, see our references page. This change package was created in March 2025 by Children’s Hospital Association quality improvement consultants and Improving Pediatric Sepsis Outcomes thought leaders and reflects best evidence to date at the time of publication. Pediatric sepsis evidence is always evolving, and readers should make every effort to ensure incorporation of the latest best evidence during implementation of sepsis improvement projects.