How to Boost Your Sepsis Bundle Compliance

We can all agree that CMS’s Severe Sepsis and Septic Shock: Management Bundle (SEP-1) measure is a tough nut to crack. 

We had the privilege of chatting with Carrie Herrmann, the SEP-1 guru at Stormont Vail Hospital, a 586-bed acute care referral center in northeast Kansas. For the past five years, Carrie and the sepsis committee at Stormont Vail have transformed the hospital’s “sepsis culture” and dramatically improved their sepsis bundle compliance as a result. Read on to see how they did it—and why they’re actually looking forward to SEP-1’s move into the Hospital Value-Based Purchasing Program in FY 2026.

How did you become Stormont Vail’s in-house SEP-1 expert?

Carrie: Well, I'll tell you, I’ve had a wonderful, varied healthcare career over the last 27 years, and I’ve done a lot of different things in the realm of quality, including serving as a surgical/ICU quality coordinator. When I joined the team at Stormont Vail five years ago, they were just getting started with the SEP-1 bundle. I was on our sepsis committee before I actually was running it, so I had the opportunity to be a part of our efforts from the very beginning. Over time, we’ve built up so many resources and education that following the bundle is now ingrained into everything we do. It’s a part of life here.

What are the benefits of having a dedicated SEP-1 specialist like yourself on staff?

Carrie: I think it’s really helped our hospital in terms of having someone who is completely on top of the specs, the constant changes, and the data—and how it all relates to our unique hospital and patient population. There is a level of trust because the team knows that our policies and education modules are up to date and that, if we’re making changes to our processes, I’m there to help them understand the “why” behind what we’re doing and how it will impact the patient.

It also means I have a degree of autonomy to experiment with different elements that I think might be worth looking at from month to month. For example, are we ordering fluids upfront when a patient is in the ED? If not, why? I can put that out there and get feedback from our providers to determine if it’s relevant or not. 

It’s important to point out that I’m not doing this alone. We have an incredible sepsis committee made up of amazing sepsis champions.

Let’s talk about your sepsis committee. What does that team look like?

Carrie: We started as a larger sepsis work group and then revamped into a smaller sepsis committee comprised of a dedicated team of stakeholders who are essential to our SEP-1 success. The committee is interdisciplinary and includes ED and hospitalist champions, nurse managers, and informaticists. We come together monthly to do a deep-dive into any non-compliant cases and to identify trends and actionable items. Then our committee members take the findings back to their regular staff huddles. Our staff is probably talked to death about sepsis [laughs]. But it’s all good; we just want to make sure we’re staying ahead of the game for our patients.

How exactly do you review your non-compliant cases? What does that process look like?

Carrie: That actually starts with my weekly chart audits. If I identify a non-compliant case, I create a slide with all the elements at play: where we were when our bundle elements should have happened, and all of our opportunities to improve. That slide is sent out to the applicable managers, providers, and sepsis champions.So, the education happens almost immediately. Then it’s the committee’s job at the monthly reviews to look at the non-compliant cases holistically in order to identify trends and system-wide action items.

What kind of sampling do you do as part of your overall auditing and evaluation?

Carrie: For a hospital of our size, the recommended sample is 20 per month. But we are a hub for other smaller hospitals, so we get a lot of transfers in, and we have a very large sepsis population. So, I audit 10 cases a week, 40 a month. We want to make sure that we are truly looking at our sepsis cases, and having that oversample helps us weed out exclusion cases. It’s our way of making sure what we’re doing is accurate and specific to our facility and to what we need to do for our patients.

Are your providers receptive to all the feedback you give them? 

Carrie: Very much so. The bundle can be complex. But once you understand the ultimate goal of the bundle is to produce standardized, highly effective practices towards creating great outcomes for your patients—and you see how all the inner pieces of that bundle are working together towards those goals—then I think it’s easy to get on board with it.

But, as you hinted at before, getting a team to that point requires a lot of education.

Carrie: Exactly. We have across-the-board resources and training, so now it’s just a part of our culture here. All our new providers and hospitalists go through the same sepsis training so that they understand our documentation and the expectations that we have. We also have yearly competencies—yearly education modules—that are sent out to all of our providers and nurses. I make sure they’re updated per the most recent bundle specs. On top of that, we provide our staff with a lot of tools, like sepsis badge buddies, sepsis screening tools to help our nurses with patient handoffs, and our MEWS [modified early response score] monitors that make it easier for our teams to jump in and facilitate treatment. 

How have all these efforts translated into your SEP-1 performance?

Carrie: When our organization first started with the SEP-1 bundle five years ago, our compliance was 55%. Last month, we were 82% compliant. Naturally, sometimes we slip below 82% and sometimes we do even better. A lot of those trends depend on our staffing and patient population at any given time.

In addition to our monthly compliance rate, I make a point of reviewing our Medisolv sepsis bundle breakdown reports with the sepsis committee quarterly. I show them where we are in each bundle breakdown. A lot of times, our six-hour data looks amazing, and it’s because we don’t have as many septic shock cases. We’re recognizing and treating sepsis early on, so it’s not getting to the point of septic shock. I think it’s a real testimony to our staff and how well we do upfront with our sepsis patients.

One other thing worth mentioning is that we’ve had a lot of improvement with our fluid compliance. With the majority of our sepsis cases starting in the ED, we had not realized the differences in documentation that existed between the ED and our inpatient units. Our inpatient units use a MAR [medication administration record] that alerts the nurses when they need to document certain things, like stop times. Our ED nurses have a navigation tool that  didn’t do that. So, we added a running infusion portion to the ED navigator, and, just like that, we went from 50% of our fluid fails being due to missing documentation to absolutely no fluid fails due to missing documentation. It’s a small data capture change, but thanks to the group effort, it created a big result.

Your results are so impressive. Do you feel good about SEP-1’s upcoming move into the Hospital Value-Based Purchasing (HVBP) Program? 

Carrie: I do, and I think it's a great move by CMS. The ultimate goal is to produce the best outcomes for our patients, and motivating teams with penalties or reimbursements based on compliance is a great way to make us all remember that goal. On a tactical level, it created incentive for us to add SEP-1 as a physician compensation metric. But on a grander scale, it's spurred a renewed effort across our organization to look at our sepsis compliance and make sure we are continuing all of our strides towards our improvement. We all know how serious sepsis is. We want to make sure that we’re catching it early and providing the best care we can to keep it from progressing.