C. Difficile Prevention Collaborative: Principles and Practice in Massachusetts CDC call September 28,

2 Susanne Salem-Schatz, Sc.D., principal of Health Care Quality Initiatives, is Program Director for the Massachusetts C. difficile Prevention Collaborative. She partners with Paula Griswold in the development and management of the Collaborative, and also serves the role of improvement advisor to the Collaborative. Dr. Salem-Schatz’s practice is split into the areas of quality improvement and healthcare improvement program evaluation. Paula Griswold, MS is Executive Director of the Massachusetts Coalition for the Prevention of Medical Errors. The Coalition was established to improve patient safety and reduce medical errors. It is a statewide public-private partnership of state and federal government officials, professional associations representing hospitals, physicians, nurses, and long-term care institutions, professional liability organizations, researchers, consumers, purchasers. Who is on today’s call

3 Eileen McHale, BSN, RN, is an experienced registered nurse with a background in clinical care, patient safety, public policy and infectious disease. A member of the Massachusetts Department of Public Health staff since 2001, Eileen currently serves as the American Recovery and Reinvestment Act Healthcare Associated Infection Coordinator. She received her BSN from Boston College, Chestnut Hill, MA. Sharon Benjamin, Ph.D. principal of Alchemy, specializes in organizational behavior and leadership development. She divides her time between consulting and teaching, and is a co- author of a new book on Positive Deviance in healthcare. Dr. Benjamin worked with Plexus Institute on early groundbreaking applications of the Positive Deviance approach to the prevention of hospital acquired infections. Who is on today’s call

Plan for Today ¡ Infection prevention in Massachusetts ¡ Structure of our HAI working group ¡ Core principals guiding our learning collaborative ¡ Theory and examples from LS1 ¡ Preview some of the CDI prevention activities 4

Handouts ¡ Agenda ¡ Practice Opportunities for CDI Prevention ¡ Pulling it together ¡ WHAT- HOW-WHO-WHEN 5

Infection Prevention: a MA Priority Massachusetts Department of Public Health (MDPH) ¡ Mandate: 2006 legislation directed MDPH to develop a Statewide Infection Prevention and Control Program ¡ Development: Program was guided by recommendations of an HAI Expert Panel ¡ Structure: Program includes state regulatory and survey agency, bureau of infectious diseases and the Betsy Lehman Center for Patient Safety ¡ Leadership: Senior bureau directors accountable for program progress and advancement ¡ Focus: Meaningful data for public reporting, provision of support for collaborative learning and promotion of preventive best practices  Ongoing Guidance: Multidisciplinary Technical Advisory Group (TAG) 6

Infection Prevention: a MA Priority ¡ Massachusetts Coalition for the Prevention of Medical Errors 1 ¡ Partnership with MA Hospital Association ¡ History of Learning Collaboratives ¡ Medication Reconciliation and Critical Test Results ¡ History in Infection Prevention ( ) ¡ Leadership series ¡ Improvement Collaborative for hospitals teams ¡ CUSP 1 7

Infection Prevention: a MA Priority ¡ Masspro: QIO ¡ 9 th Scope of Work: MRSA project with 5 hospitals ¡ Institute for Healthcare Improvement ¡ Sit on Coalition Board ¡ Infection prevention Breakthrough Series ¡ CDI Prevention Expedition ¡ Centers for Disease Control ¡ Resources and experts 8

Building & Maintaining Relationships ¡ Coalition participation in DPH Leadership meetings ¡ Coalition membership on TAG ¡ Respectful collaboration ¡ Review plans, agendas materials with DPH partners ¡ Engage experts across the State 9

Collaborative Advisors ¡ Representation from ¡ Infection Prevention ¡ Infectious Disease ¡ Hospital Quality ¡ Pharmacy ¡ Collaborative & program planning ¡ Combination of formal calls and informal contact. 10

Guiding Collaborative Principles 1. Relationship – centered approach 2. Importance of engaging leadership and the front lines 3. Create opportunities for active learning ¡ Face to face meetings ¡ Expert and peer support conference calls 4. Combine existing evidence with opportunities for discovery and reinvention 11

Relationship-Centered Approach ¡ Began with needs assessment calls to identify priorities: participants set the agenda ¡ Keep attention and focus on the work ¡ Jumpstart conversation on the list serve ¡ Periodic phone calls to follow up on activities, reports and measures ¡ Create opportunities for teams to get to know each other 12

Engaging Leadership and the Frontline ¡ Kickoff conference call for leaders ¡ Presentations by hospital CMO and CNO about leadership approaches they use to support infection prevention. ¡ Require multidisciplinary teams for collaborative participation 13

Engaging Leadership and the Frontline ¡ Infection Preventionist* ¡ CMO / CNO / Other executive sponsor ¡ Physician champion * Preferably not the team leader ¡ Nurse champion ¡ Environmental Services ¡ Laboratory ¡ Pharmacy ¡ Front line staff from pilot units 14 Teams may include:

Engaging Leadership and the Frontline ¡ Keeping engagement strong ¡ Communications with executive sponsors ¡ Monthly conference calls for the whole team ¡ Expert calls ¡ Coaching and sharing calls ¡ Stay on the radar ¡ Promote listserve conversation ¡ Periodic calls to individual team leaders 15

Create Opportunities for Active Learning ¡ Incorporate principles of adult learning into face-to-face meetings ¡ Begin meeting with active conversation across teams ¡ Opportunities and tools to encourage reflection and discussion between speakers ¡ Some tools ¡ Presentations on process as well as content ¡ Practice new behaviors 16

Create Opportunities for Active Learning ¡ Purposeful pursuit of participation and conversation on coaching calls ¡ Be familiar with team progress before the call ¡ Recruit team leaders to jumpstart the conversation ¡ Observe: what questions lead to conversation? ¡ What’s up this month?  ¡ What could we do that would be helpful?  17

Balance Evidence with Opportunities for Discovery and Reinvention ¡ Offer opportunities to learn and share ¡ Encourage self discovery and re-invention ¡ People own the ideas that they create or adapt to their setting. ¡ Combine ‘best practices’ with self organizing approaches ¡ Encourage reflective learning ¡ small tests of change – PDSA cycles ¡ multiple roles for data and measurement 18

Balance Evidence with Opportunities for Discovery and Reinvention ¡ Informed by principles of Positive Deviance 1 ¡ Staff ownership NOT buy-in therefore nothing about me without me ¡ Focus on existing & latent solutions using available resources ¡ Shift from telling to asking ¡ Emphasize local innovation and small changes ¡ Solution-centric 19 1 Singhal, A., Buscell, P., & Lindberg, C. (2010) Inviting Everyone: Healing Healthcare through Positive Deviance, Bordentonwn, NJ: Plexus Press

Putting Learning & Discovery into Action ¡ Practice Opportunities for CDI Prevention ¡ Combined guidance from multiple sources ¡ Pulling it together ¡ What do we do now? What keeps us from doing it all the time? What else could we try? ¡ WHAT- HOW-WHO-WHEN ¡ Practice Recommendation ¡ Changes we can try ¡ Who needs to be in the room? (Think beyond the usual suspects) ¡ How will we know it’s working? (Measures) ¡ What will we do next week? 20

MA CDI Prevention Collaborative Kickoff: June 2010

Some things teams are doing ¡ Screening guidelines ¡ Lab processing protocols ¡ Cleaning assessment, process and products ¡ Contact precautions ¡ Cohorting policy ¡ Hand hygiene ¡ Antibiotic stewardship 22

How are teams doing it ¡ Conducting small tests of change ¡ We will be testing our new policy changes on 3 pilot units. ¡ Creating efficiencies ¡ Testing for C. difficile is now being done 24/7 using Cepheid GeneXpert. The test is so specific and sensitive that the presence of the organism can be confirmed by testing one specimen. Staff no longer need to test three specimins from the same patient. ¡ Communicating with leadership ¡ This work is reported through the Infection Control Committee, Quality & Pt. Safety Council, Medical Executive Committee, and ultimately to the Board of Trustees. We have received full support for the initiative from these bodies. 23

How are teams doing it ¡ Engaging front line staff ¡ I was delighted that utilizing the front line staff increased staff participation and was encouraged by the honest responses. ¡ Changing the culture ¡ We are bringing human resource to the table to address staff accountability relative to Infection Prevention Practices ¡ Strengthening relationships and having fun ¡ The Infection Prevention Department and the Environment of Care Department are sponsoring a fair, with a competition among EOC teams to clean rooms that have been marked with a substance that is revealed with ultra-violet light. There will be prizes! 24

Still Learning Stay tuned……. 25