Peter Pronovost, MD John R. Combes, MD

1. Using Collaboratives to Reduce Central Line-Associated Bloodstream Infections (CLABSI):A National Implementation Program Peter Pronovost, MD John R. Combes, MD

2. Overview • Context and National Leadership • State Level Consortia • Sustainability • Q&A

3. National Contextand Leadership

4. HHS Steering Committee for the Prevention of HAI • Charge: Develop an Action Plan to reduce, prevent, and ultimately eliminate HAIs • Plan will: • Establish national goals for reducing HAIs • Include short- and long-term benchmarks • Outline opportunities for collaboration with external stakeholders • Coordinate and leverage HHS resources to accelerate and maximize impact

5. Steering Committee Working Group Structure

6. HHS Action Plan • Initial version issued in January 2009 • Public comment received in February 2009 • Revision finalized in June 2009 • HHS Action Plan Website http://www.hhs.gov/ophs/initiatives/hai

7. HAI Priority Areas Catheter-Associated Urinary Tract Infection Central Line-Associated Blood Stream Infection Surgical Site Infection Ventilator-Associated Pneumonia MRSA Clostridium difficile Implementation Focus Hospitals Tier One Priorities *Tier Two will address other types of healthcare facilities

8. Reduce Surgical Infections and Complications Reduce Central Line-associated Blood Stream Infections (CLABSI) Reduce methicillin-resistant Staphylococcus aureus (MRSA) Reduce clostridium difficile infections (c diff) Reduce ventilator-associated pneumonia (VAP) Reduce catheter-associated urinary tract infections Reduce adverse drug events from high-hazard medications (e.g., anticoagulants, narcotics, opiates, insulin, sedatives) Reduce pressure ulcers AHA’s Hospitals in Pursuit of Excellence

9. State Consortia

10. Project Organization • Statewide effort coordinated by State Hospital Association including QIOs and State DOHs • Collaborative model • Standardized data collection tools and evidence • Local ICU modification of implementing interventions • Implementing interventions outside the ICU

11. Participating States • 10 states with at least 10 hospitals in 2008-2011 California North Carolina Colorado Ohio Florida Pennsylvania Massachusetts Texas Nebraska Washington

12. CUSP EXPANSION • All hospitals within the states are eligible • The following states are in the expansion: Alabama, Alaska, Arizona, Delaware, District of Columbia, Idaho, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Mississippi, Montana, Nevada, North Dakota, Puerto Rico, South Dakota, Utah, Vermont, Virginia, Wyoming

13. Arkansas Hospital Association Connecticut Hospital Association Georgia Hospital Association Healthcare Association of Hawaii Illinois Hospital Association Indiana Hospital Association Minnesota Hospital Association Missouri Hospital Association New Hampshire Hospital Association New Jersey Hospital Association New Mexico Hospital Association Healthcare Association of New York State Oklahoma Hospital Association Oregon Hospital Association South Carolina Hospital Association Tennessee Hospital Association West Virginia Hospital Association Wisconsin Hospital Association JHU Funded State Projects

14. State Consortia Members • State hospital associations • QIOs • State health departments May include • Payers • PSOs • Government officials • Business 8

15. State Hospital Associations • Serve as project coordinator for state consortia and participating hospitals • Facilitate conference calls and in-person meetings with HRET/JHU/MHA faculty • Oversee collection of CLABSI and safety culture data

16. Role of QIOs • Part of state infrastructure—lend expertise and other resources to support initiative • Participate in conference calls, in-person meetings

17. Building State Programs to Prevent HAIs • Project Description: • Create and expand state-based HAI prevention collaboratives • Build a public health HAI workforce in states • Enhance states abilities to assess where HAIs are occurring • Agency Lead: CDC • Collaborating Agencies: AHRQ and CMS • Funds Source & Amount: ARRA ($40 M) • CDC HAI Recovery Act Website http://www.cdc.gov/nhsn/ra

18. Consortia Organization • Lead Partner Role: State Hospital Association or affiliated state hospital association organization coordinating the state-wide collaborative. • Advisor role: will support the collaborative effort with infectious disease expertise. • Endorser role: will support the collaborative by promoting On the CUSP: Stop BSI and by providing cash or in-kind resources such as meeting space.

19. NC Safer ICUs: Eliminating CLABSI Collaborative

20. Florida Consortium

21. Evolving Consortia Roles • SHA • Recruitment, Marketing, Convening • QIO • Training, Field Agent • DOH • Technical Support, Analysis, Epidemiology

22. Sustainability

23. State Consortia & Sustainability • State consortia key to sustainability: • Train-the-trainer education to build capacity for future patient safety innovations, e.g., On the CUSP: Decubiti • Evaluation component to identify lessons, including critical success factors and barriers

24. FLEXTRA Kit • A model for the development of resource materials to support instructor-delivered in service training and faculty development • Contains: • Instructors/Leader’s Guide • Camera ready materials for handouts • Presentation materials (PowerPoint slides & videos) • Evaluation instruments • Battles JB, Sheridan MM The FLEXTRA Kit: a model for instructor • support materials. J Biocommunication; 1989:6;3;1-13. 6

25. CUSP FLEXTRA Kit • Begins with all existing content as well as new content developed as part of the project • Identifies key concepts to be illustrated through video vignettes • Work with experts in CUSP, care in each selected hospital unit, and adult learning to develop storyboards and final scripts for the vignettes • The compilation of the video vignettes supervised by clinical experts • The embedding of the video content into DVD and CD format suitable for bundling with other training materials • The development and editing of the instructional guides, in collaboration with experts in both CUSP and adult learning concepts • The final bundling of all the resources into print and electronic formats that are: • Fully in the public domain • 508 compliant • Branded as an AHRQ product, but designed to be co-branded

26. Hospital Core team p repare s State Coordinat or s / representatives work State Coordinators core team prepare with QI staff at their to implement CUSP - hospital teams of hospitals to CLABSI using a representatives to implement CUSP - Professional implement CUSP - CLABSI, blanketing Development CLABSI using a all relevant hospital Workshop that Train the Trainer staff in the relevant a. familiarizes them method that training and rolling with the project and a. familiarizes them out CUSP - CLABSI. the materials; with the project and State Coordinators / b. teaches them how the mater ials; core team provide to teach using these b. teaches them how follow up coaching materials; and to teach using these calls to hospital c . teaches them how materials; and representatives. to facilitate others in c. teaches them how implementing to facilitate others in implementing CUSP - CLABSI CUSP - CLABSI Core team 12 200 20,000 State coordinators team s Hospital representatives team s Hospital workers Emanuel,L (2009)

27. Conclusion

28. HAI Elimination Collaboration Policy Leadership AHRQ CDC CMS AHA Field Leadership JHU MHA HRET NW Implementation Leadership SHA DOH QIO

29. Summary • National Commitment • Strong Collaboration • Federal Agencies • Provider Organizations • State Stakeholders • Local Consortia Sustainability • Unit Based Culturally Driven Improvements

30. Questions