AHRQ Annual Meeting Sept. 27, 2010 Steve Hines, PhD Health Research and Educational Trust

1. Building National Health CareQuality Improvement Campaigns to Succeed:Lessons from the CUSP: CLABSI Project AHRQ Annual Meeting Sept. 27, 2010 Steve Hines, PhD Health Research and Educational Trust

2. Presentation Overview • CUSP: CLABSI Project Origins and Background • The Challenge of Evolving a National Project • Implications for Project Design and Planning • Final Thoughts

3. Project Origins and Background In the beginning was the Keystone Project . . . . . . and it was very good!

4. CUSP: CLABSI Project Rationale • Blood stream infections kill 40,000-60,000 persons each year. • Reducing the BSI rate from 5 per 1,000 days to 1 per 1,000 days will save 20,000 lives annually. • Michigan Keystone Project showed that this level of reduced CLABSI rate was achievable and sustainable. • Project made central part of Secretary Sibelius’ Healthcare Acquired Infection Reduction Initiative.

5. CUSP: CLABSI Project Goals • Outcome Goals: • Reduce BSIs to 1 per 1,000 central line days • Some states and hospitals view CLABSI elimination as the goal • Improve unit safety culture • Reach hospitals in all 50 states, the District and Puerto Rico • Include both ICUs and other units with CLABSI risks • Include critical access hospitals

6. CUSP: CLABSI Implementation Content CUSP CLASBI Wash hands prior to procedure Use maximal barrier precautions Clean skin with chlorhexidine Avoid femoral lines Remove unnecessary lines • Educate on the science of safety • Identify defects • Assign executive to adopt unit • Learn from defects • Implement teamwork and communication tools

7. CUSP CLABSI Intervention Processes Individual Components • Planning/ orientation calls • Baseline data collection period for CLABSI and safety culture • Kickoff meeting • Monthly infection rate and team process data submission • Monthly content calls • Monthly coaching calls • Monthly feedback reports on outcome and process measures • Mid-course meeting • End-of-project meeting Project spans two years and requires participation in: • 2-3 in-person meetings • 48-60 calls led by national project team • 24 internal meetings of implementation team • Monthly data collection, submission, and assessment (lessons learned/root cause analysis)

8. The Challenge of Evolving a National QI Project

9. A Tale of Two Airplanes

10. Obstacles to Evolving • Proven initial model: Change distances project from proof method will work • Project databases: Stability justifies creating and building a robust national database • Evaluation: Simpler and cleaner to assess outcome of a single intervention • Project planning: Proposal submission process requires plan easier to execute than to modify • Budgets/Contracts: Executed agreements with subcontractors commit resources for specific tasks • Clarity: Change creates questions and confusion

11. Lessons from Two Airplanes Change is difficult, risky, but absolutely essential for mass production (or a national rollout to succeed.

12. Predictable Evolutions in National QI Campaigns • Key challenge shifts from obtaining proof change is possible to achieving change in specific units. • Baseline problem level changes from 5 infections per 1,000 central line days to 2-3 infections per 1,000 central line days. • Goal changes from under 1 infection per 1,000 central line days to total elimination .

13. Predictable Evolutions in National QI Campaigns • Participant expectations change from uncertainty of success despite effort to (over)confidence in success with minimal effort. • Participants change from innovators and early adopters to mid- to late-majority hospitals. • External environment changes from project as unique and innovative to project as one of many improvement activities in the area.

14. National QI Campaign Paradoxes • The more successfully a national QI campaign begins, the more pressure there will be for it to remain unchanged and the more need it will have to evolve quickly and substantially. • Nothing guarantees failure more than continued, unreflective reliance on the processes that first produced success.

15. Preparing to Successfully Adapt to Change

16. Preparing to Successfully Adapt to Change

17. Preparing to Successfully Adapt to Change

18. Implications for Leaders of National QI Campaigns and Funding Organizations • Proposal Evaluation • Budgeting • Goal Setting • Project Leadership • Operational Processes • Data Bases • Evaluation

19. Implications for Leaders of National QI Campaigns and Funding Organizations: Key Questions

20. Implications for Leaders of National QI Campaigns and Funding Organizations: Key Questions

21. Final Thoughts • Critical to distinguish between essential success factors and processes for helping hospitals implement them. • Success factors for CUSP: CLABSI • Culture change that makes safety a priority and empowers every employee to hold every other employee accountable for safety • Operational changes that reduce infections • Processes likely to morph: Set of meetings and calls used to educate, motivate, and empower unit staff to implement CUSP: CLABSI.

22. Final Thoughts • Critical to recognize inherent tensions in national campaigns. • Consistency & clarity vs. need to change • Strong national leadership vs. flexible local leadership • Design that supports strong, clean evaluation of impact vs. design that maximizes operational impact • Processes likely to morph: Set of meetings and calls used to educate, motivate, and empower unit staff to implement CUSP: CLABSI • More research and reflection required on how to make national campaigns successful and efficient (e.g. Scale Up & Spread Conference funded by AHRQ, Commonwealth Fund & others.

23. Final Thoughts • Need to account for context in planning and executing a campaign: • Inevitable that parts of campaign will not take place in ideal context • Could be ideal when funded, less enthusiasm during implementation • Could be ideal at kickoff, but requires visionary funder that correctly times the trend • Need strategies for both directly influencing participants and for shaping the national environment to support campaign’s goals.

24. Questions • About presentation: • Steve Hines SHINES3@AHA.ORG 312-422-2607 • About participating in CUSP: CAUTI or CUSP:CLABSI DBOHR@AHA.ORG 646-678-4280 Disclaimer: Although the CUSP:CLABSI project is funded by AHRQ and is being led by a partnership that includes Johns Hopkins University and the Michigan Health and Hospital Association, the opinions in this presentation are exclusively those of the presenter. Like an effective national campaign, these views are also likely to evolve over time.