Electronic Health Record-Embedded Structural Interventions to Improve Sepsis Bundle Quality Measure Performance: A Quality Improvement Initiative at a Veterans Affairs Medical Center

Abstract

Background: Though emphasized as a quality metric, sepsis quality measure (SEP-1) compliance remains low nationwide. Electronic health record (EHR)–based interventions show promise, but few have examined EHR laboratory reference value misconfiguration as a distinct driver of noncompliance. Local Problem: The San Francisco Veterans Affairs, a 110-bed tertiary care center, recorded 3 consecutive quarters of SEP-1 composite performance in the lowest national quintile, nadiring at 31.5%. Methods: A multidisciplinary team applied LEAN-A3 methodology to identify root causes of low SEP-1 performance and design targeted countermeasures. The primary outcome was the percentage of suspected sepsis patients with a serum lactate >2.0 mmol/L who received a repeat lactate within 6 hours. Balancing measures included unnecessary repeat lactates and sepsis mortality. Interventions: Three EHR-based interventions were implemented between August and November 2025: (1) an Emergency Department Sepsis order-set embedding dual time-spaced lactate orders; (2) a structured Sepsis Evaluation Note template; and (3) a clinical decision support alert for patients with serum lactate >2.0 mmol/L, implemented to address a laboratory reference range misconfiguration. Results: Postintervention lactate reassessment compliance rose 14 percentage points (54%–68%), meeting Institute for Healthcare Improvement criteria for special cause variation. Facility 12-month rolling performance rose from 31.5% (lowest quintile) to 64.7% (middle quintile), reaching a quarterly high of 74.3%. No increase in unnecessary repeat lactates or sepsis mortality was detected. Conclusions: EHR-embedded structural interventions produced sustained SEP-1 improvement without impacting laboratory utilization or mortality, offering a reproducible model for improvement through systems redesign rather than education alone.