Lessons from CUSP/CLABSI – Getting to Zero and Sustaining your Improvements

1. On the CUSP: Stop BSI Lessons from CUSP/CLABSI – Getting to Zero and Sustaining your Improvements Jill Marsteller, PhD, MPP Armstrong Institute for Patient Safety and Quality Elizabeth Martinez, MD Massachusetts General Hospital

2. Learning Objectives • To revisit key aspects involved in reducing infections • To think ahead about ways to make your investment of time and improvements in BSI rates last forever (embed) • To consider how to apply CUSP to other relevant topics (expand) and maintain its positive effects in your area (embed) • To make sure all patients in your institution have access to the safest care (expand)

3. What it takes…… 12 Best Practices to Eliminate BSI’s

4. Best Practices • Commit to zero • Teams where the senior executive committed to zero do better! • ICU is accountable for the problem • Senior leader holds the ICU-level leaders accountable • Senior leader expects the unit leaders to present their data to the senior leaders, board of trustees • Senior leader expects the unit to investigate every CLABSI

5. Best Practices • Infection preventionists work with the unit • Train, monitor and help investigate infections • IPs should be a part of the team! • Unit physicians and nurse leaders own the problem. • Avoid the femoral site • Key is avoidance of the site associated with highest infection rate – Focus on this!

6. Best Practices • Make doing the right thing easy! • Have ALL of the necessary items for line placement easily available • Line cart or Line kit with all of the items together • Everybody knows where they are • Make sure they are ALWAYS available • Have a system in place to ensure this • Standardize the line placement process across the ICU and the hospital.

7. Best Practices • Empower all provides to STOP the process if a problem is noted during line placement • Make certain that the front-line providers feel supported and they know who they can call. • Investigate all CLABSIs as defects • Avoidable errors • Examine all steps of the process • Was the checklist used? • Where was it placed? • Do they think it is associated with placement or maintenance? • What is the plan for prevention of the next infection?

8. Best Practices • Review and audit catheter maintenance • Review the policies and practices • Physically audit the process • Are dressings in place? • Observe the process of a dressing change. • What are local processes for tubing changes? • What is being done when lines are accessed?

9. Best Practices • Train all new team members • Have system to train new nursing staff • Have system to train new resident/mid level staff • Include in the training • The expectations for placement and the ICUs goal of zero line infections • That all staff are empowered to stop the process

10. Best Practices • Share data • Post data in the ICU so that everybody sees and understands it • Post both quarterly rates AND weeks without any infections • Report data with senior leaders • EVERYBODY in the unit should know their CLABSI rates and weeks without an infection!

11. Two More E’s • EMBED • EXPAND

12. Implementation Framework

13. Implementation Framework

14. Embed—Plan for Sustainability • Why worry about the distant future? • What you can anticipate: • Turnover of staff/new staff • Changes in policy (system, hospital, national) • New projects/distractions • Complacency • Emergencies and complex cases (someone will call for exceptions to be made)

15. Embed—Plan for Sustainability • Things you can do now to support long term viability of the CLABSI reduction • Write it into policy • Include in training for all new members • Audit or monitor to be sure it is routine practice • Set up reliable supply chain (borrowing protocol; alert system; assign someone)

16. Implementation vs. Sustainability Where will you be? Marsteller, Pronovost, Shortell. “Improving Quality of Care: Good Implementation is not Enough.” 8/11. Submitted to a peer reviewed journal; do not copy, re-use or cite without permission.

17. Embed—Plan for Sustainability • Set up a Learning Network of peers • Build infrastructure for sharing lessons locally and system-wide • Plan your line of succession • Promote, examine and *work on* culture of safety

18. 4 yr CLABSI Results from ICUs in Michigan Pronovost et al. BMJ 2010

19. Embed—Plan for Sustainability Practices that aided sustainability in the Michigan Project • Continued feedback of infection data that the team perceived as valid • Improvements in safety culture that occurred as part of the overall Keystone ICU project • An unremitting belief in the preventability of bloodstream infections • Involvement of senior leaders who reviewed infection data and provided teams with the resources needed • A shared goal rather than a competition to reduce infection rates throughout the state

20. Embed—Plan for Sustainability Things you can do now to support long term viability of your CUSP program • Maintain your CUSP team • Consider rotating membership • 40+ Teams at JHH-- some going 10 years • Collect the Staff Safety Assessment on ongoing basis • Keep Learning from Defects • Keep your executive (“the project” is not over) • Develop hospital-wide CUSP team or meeting

21. Embed—Plan for Sustainability continued • Does everyone on your unit feel part of the CUSP team? • If not, re-evaluate your CUSP team: • Are all staff encouraged to attend? • Is your executive partner, physician, and infection preventionist present and engaged at every meeting? • Are there others that need to join? (ex., respiratory therapy)

22. Embed—Plan for Sustainability • Is there a sense of ownership of the CUSP team on your unit? • Incentives (evaluation, promotion) for second-order problem solving / learning from defects • Everyone is a problem solver • Repeat culture of safety surveys, may show CUSP success • Use CUSP tools (Culture Checkup) to keep working on safety culture

23. Expand--Spread CLABSI Interventions • Why think about expanding to other units? • To make sure all patients in your institution have access to the safest care • Solidifies own knowledge of CLABSI prevention, investigation • Unique challenges of other units may offer new ideas and methods/may change your perceptions of your own implementation

24. Expand CUSP to Identify New Defects • Why think about your next defect? • Quality can always improve • Use new capacity to change to make care better • Maintain engagement of staff/interest and attention of management • Allows some control over what the next initiative will be • More rewarding environment

25. Expand CUSP to Other Units • Why do we spread CUSP to other units? • To make sure all patients in your institution have access to the safest care • Improve culture throughout the institution • To create a standard language and understanding of the science of safety • To become a high reliability organization

26. Expand CUSP to Other Units • How do we spread CUSP to other units? • Requires leadership endorsement and support • Resources allocated will determine extent and speed of spread • Human resources, protected time on unit-based teams for champions, training needs • Consider organizational infrastructure to expand

28. Reference List • Buchanan D, Fitzgerald L, Ketley D, Gollop R, Jones JL, Saint Lamont S, Neath A and Whitby E. No going back: A review of the literature on sustaining organizational change. International Journal of Management Reviews 2005; 7(3):189-205. • Evashwick C, Ory M. Organizational characteristics of successful innovative health care programs sustained over time. Fam Community Health. 2003 Jul-Sep;26(3):177-93. • Greenhalgh T, Robert G, Macfarlane F, Bate P and Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004;82(4):581-629. • Pronovost, PJ et al. “Sustaining Reductions in Catheter-Related Bloodstream Infections in Michigan Intensive Care Units”British Medical Journal, February 4, 2010; 340:c309.