1 What Factors Affect Bundle Uptake in a Voluntary Quality Improvement Campaign? An Assessment of Project JOINTS Dmitry Khodyakov, PhD, MA M. Susan Ridgely, JD, MS Christina Huang, MPH Melony E. Sorbero, PhD, MS, MPH Eric C Schneider, MD, MSc

2 Declaration of Competing Interests All authors report no competing interests This study was funded by a grant (R18 AE000051) awarded to the Institute for Healthcare Improvement and the RAND Corporation by the U.S. Department of Health and Human Services

3 Background Research points to delays in hospital adoption of evidence-based practices The Institute for Healthcare Improvement (IHI) introduced a series of innovative strategies to accelerate the spread of such practices IHI campaign model is an approach that leverages inter-organizational ties and interpersonal influence

4 Project JOINTS Project JOINTS (Joining Organizations IN Tackling SSIs) is one of the latest IHI campaigns Two cohorts of hospitals (n=323) from 10 U.S. states were recruited Project JOINTS was conducted in Hospitals implemented a 5-component bundle to prevent the spread of surgical site infection (SSI) after hip and knee arthroplasty

5 Project JOINTS SSI Prevention Bundle 1.Use an alcohol-containing antiseptic agent for preoperative skin preparation 2.Instruct patients to bathe/shower with CHG soap for 3 days before surgery 3.Screen for Staphylococcus aureus (SA) carriage and decolonize SA carriers with 5 days of mupirocin and 3 days of chlorhexidine soap prior to surgery 4.Appropriate use of prophylactic antibiotics 5.Appropriate hair removal

6 Rapid Spread Network (RSN) RSN is a network of state-level organizations (nodes) that help hospitals catalyze quality improvement This field infrastructure was developed by IHI during its 100,000 Lives and 5 Million Lives Campaigns

7 Research Questions What role did the RSN “nodes” play in Project JOINTS? Are hospital adherence to quality improvement (QI) methods and the level of hospital engagement in the project associated with the bundle uptake?

8 Research Methods Node Interviews – 11 semi-structured interviews with node representatives from Cohorts 1 and 2 – Data were analyzed thematically utilizing Maxqda Hospital Key Informant Interviews – 73 structured interviews with Cohort 2 hospital representatives (67% participation rate) – Responses were analyzed both qualitatively and quantitatively

9 Project JOINTS Logic Model

10 Node Engagement in Project JOINTS Potential Project JOINTS Node ActivitiesN Dissemination of information about IHI’s resources to hospitals9 Organization of site visits, town halls, and/or calls9 Hospital identification and recruitment8 Facilitation of hospital-to-hospital learning (use of listserv)7 Identification of exemplar hospitals7 Assisting hospitals with questions4 Supporting hospitals in tracking Project JOINTS intervention progress2 Acknowledgement of successful facilities2 Dissemination of information about Project JOINTS via newsletters and press releases 2 Alignment of Project JOINTS activities with other QI initiatives0 Assisting hospitals with implementation activities0

11 Two Benefits of Node Engagement Expedite Hospital Recruitment – Have most updated hospital information – Know appropriate contacts Play an Intermediary Role between IHI and Hospitals – Familiar and trusted source of information – Understand local context and add a personal touch

12 Adherence to Quality Improvement Methods, Hospital Engagement, and Bundle Uptake

13 50 out of 73 Responding Hospitals Used ≥1 Project JOINTS QI Methods

14 Hospital Engagement in Project JOINTS

15 Webinar Calls, Electronic Communications, and How-To Guides Were Most Popular

16 More Than Half of Participating Hospitals Adopted the Complete Bundle However, most hospitals were already using three of the five components consistently: – Alcohol-containing antiseptic (74%) – Appropriate prophylactic antibiotics (85%) – Appropriate hair removal (99%) Roughly a third of hospitals reported no change in their practices Hospitals reporting change focused on new components

17 Complete Bundle Adoption is Positively Associated with: The Use of Project JOINTS QI Methods – OR=2.05; 95% CI: , p≤.1 AND Hospital Engagement in Project JOINTS – OR=1.32; 95% CI: , p≤.1

18 Initiation/Improved Adherence to Bundle Components is Only Associated with: Hospital Engagement – IRR=1.11, 95% CI: , p≤.05 The Use of Campaign Materials and Tools – IRR=1.13, 95% CI: , p≤.05

19 Conclusions: The Role of the RSN Nodes T o identify and recruit hospitals To confer legitimacy to the project To be a conduit of information rather than a provider of hands-on assistance

20 Conclusions: Bundle Uptake More than half of Project JOINTS hospitals adopted the complete bundle – Most were already using 3 bundle components before Project JOINTS – Some reported only partial compliance – Roughly a third of hospitals reported no change in their practices

21 Conclusions: Factors Affecting Bundle Uptake The use of QI methods and hospital engagement are positively associated with complete bundle adoption The use of online and printed IHI materials is positively associated with initiation/improved adherence to bundle components

22 Lessons Learned Future campaigns may benefit from increased efforts to actively engage hospitals Nodes may help do this because they are perceived as trusted conduits of information Attention should be paid to campaign materials as they are important for bundle uptake Hospitals should understand and accept evidence behind bundle components Components should be relatively easy to implement