1. 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 Quality Elizabeth Martinez, MD Massachusetts General Hospital

2. 2 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

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

4. 4 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

5. 5 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

6. 6 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

7. 7 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

8. 8 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

9. 9 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

10. 10 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

11. EMBED EXPAND Two More E’s

12. 12 Frontline Staff Team Leaders Senior Executives Engage Ask, how does this make the world a better place? Educate What do I need to do? Convert evidence into behaviors; evaluate awareness and agreement Execute How can I do it? Listen to resisters Standardize, create independent checks, and learn from mistakes Evaluate How do I know we made a difference? Implementation Framework

13. 13 Frontline Staff Team Leaders Senior 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 units Identify and address your next challenges Implementation Framework

14. 14 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

15. 15 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

16. 16 “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.

17. 17 − 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

18. 18 Time periodMedian CLABSI rate 19-21 months0 22-24 months0 25-27 months0 28-30 months0 31-33 months0 34-36 months0 4 yr CLABSI Results from ICUs in Michigan Pronovost et al. BMJ 2010

19. 19 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

20. 20 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

21. 21 − 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 Sustainability continued

22. 22 − 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

23. 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. 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. 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. 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

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28. 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.