Two More E’s and How to Spread

Learning Objectives To think ahead about ways to make your investment of time and improvements in BSI rates last forever To make sure all patients in your institution have access to the same level of safety in their care

Implementation Framework

Endure—Plan for Sustainability Why worry about the distant future? What you can anticipate − Turnover of staff and new staff − New projects and distractions − Complacency − Emergencies and complex cases (someone will call for exceptions to be made)

Things you can do now to support long-term viability of BSI 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) − Have a quarterly review by executive partner − Set up a learning network of peers − Have regular meetings with your infection preventionist Endure—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 Unremitting belief in the preventability of blood stream infections Involvement of senior leaders who reviewed infection data and provided teams with needed resources Shared goal rather than a competition to reduce infection rates throughout the State Pronovost, PJ; Goeschel C., et al. “Sustaining Reductions in Catheter-Related Bloodstream Infections in Michigan Intensive Care Units” British Medical Journal, February 4, 2010; 340:c309.

Expand—Spread the Intervention Why think about expanding to other units? – Requires self study – Solidifies own understanding – Provides equal protection for all patients (lines are placed elsewhere) – May offer new ideas and methods or may change your perceptions of your own implementation when you see other units’ unique challenges

Expand—Spread to New Projects Why think about your next project? – Can always improve quality – Use new capacity to change to make care better – Maintain engagement of staff and interest and attention of management – Permits some control over what the next initiative will be – Offers a more rewarding environment

IHI’s A Framework for Spread Make the project an organizational goal or strategic initiative Identify an owner or executive responsible for spread Identify person or team to manage day-to-day spread activity Bundle changes (or interventions) in an easily adopted and tested package Develop plan and targets for spread initiative Define specific goals of spread Define specific improvements that will be made Define timeframe of the spread effort Create template for feedback report to the sites for monitoring progress Massoud MR, Nielsen GA, Nolan K, et al. A Framework for Spread: From Local Improvements to System-Wide Change. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006.

Action Items Start planning now for sustaining the intervention for years to come Work with your executive partner and unit heads to expand the intervention into other units Engage staff in thinking about the next mountain they would like to climb while maintaining low BSI rates

Reference List Buchanan D, Fitzgerald L, Ketley D, et al. No going back: A review of the literature on sustaining organizational change. International Journal of Management Reviews 2005; 7(3): Evashwick C, Ory M. Organizational characteristics of successful innovative health care programs sustained over time. Fam Community Health Jul-Sep;26(3): Greenhalgh T, Robert G, Macfarlane F, et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004;82(4):