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

On the CUSP: Stop BSI

Jill Marsteller, PhD, MPP Armstrong Institute for Patient Safety and QualityElizabeth Martinez, MDMassachusetts General Hospital

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• 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)

Learning Objectives

What it takes……

• 12 Best Practices to Eliminate BSI’s

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1. Commit to zero– Teams where the senior executive committed to zero do

better!

2. 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

Best Practices

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3. Infection preventionists work with the unit– Train, monitor and help investigate infections– IPs should be a part of the team!

4. Unit physicians and nurse leaders own the problem.5. Avoid the femoral site

– Key is avoidance of the site associated with highest infection rate – Focus on this!

Best Practices

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6. 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

7. Standardize the line placement process across the ICU and the hospital.

Best Practices

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8. 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.

9. 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?

Best Practices

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10. 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?

Best Practices

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11. 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

Best Practices

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12. 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!

Best Practices

• EMBED• EXPAND

Two More E’s

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Frontline StaffTeam

LeadersSenior

Executives

EngageAsk, how does this make the world a better place?

EducateWhat do I need to do?Convert evidence into behaviors; evaluate awareness and agreement

Execute

How can I do it?Listen to resistersStandardize, create independent checks, and learn from mistakes

Evaluate How do I know we made a difference?

Implementation Framework

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Frontline StaffTeam

LeadersSenior

Executives

Embed

Has this become business as usual? How do I know it will last?Make policies and procedures, train new people, walk the process

Expand

Who else needs to know this?What’s next?Pass it on to other unitsIdentify and address your next challenges

Implementation Framework

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• 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)

Embed—Plan for Sustainability

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• 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)

Embed—Plan for Sustainability

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“High” Implementers

“Low”Implementers

“High” Sustainers

“Low” Sustainers

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.

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− 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

Embed—Plan for Sustainability

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Time period Median CLABSI rate19-21 months 022-24 months 025-27 months 028-30 months 031-33 months 0

34-36 months 0

4 yr CLABSI Results from ICUs in Michigan

Pronovost et al. BMJ 2010

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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

Embed—Plan for Sustainability

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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

Embed—Plan for Sustainability

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−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)

Embed—Plan for Sustainabilitycontinued

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− 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

Embed—Plan for Sustainability

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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

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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

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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

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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

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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.