Combination of evidence-based practice and culture change helped program succeed
Every year, 30,000–62,000 patients die as the result of central line–associated bloodstream infections (CLABSI). The Agency for Healthcare Research and Quality (AHRQ) awarded a $3 million, three-year grant in October 2008 for a program coordinated by the Healthcare Research and Education Trust to pre-vent such infections.
The grant expands on an existing project started by the Johns Hopkins University (JHU) in Baltimore and the Michigan Hospital Association’s (MHA) Keystone Center for Patient Safety & Quality in Lansing.
Led by Peter Pronovost, MD, PhD, director of the Quality and Safety Research Group at JHU, the pilot project was implemented in more than 100 ICUs in Michigan hospitals and dropped infection rates to zero in half of the participating ICUs.
“Not only will we save lives and reduce costs of care, but we’ll put joy back into the hearts of many -clinicians who are often feeling demoralized and, more importantly, we’ll build capacity to tackle the next problem,” says Pronovost about his goal of preventing CLABSI.
Pronovost is a part of this next phase of the project, which will involve 10 hospitals within 10 identified states. The AHRQ is responsible for approving the 10 states based on their level of interest and readiness to take part in the effort. A goal for the national project is to drop CLABSI by 80% to one infection per 1,000 catheter days. The project is centered on the Comprehensive Unit-Based Safety Program (CUSP). CUSP is built on the idea of improving the culture of safety on a specific unit by identifying what staff members think problem areas are and then changing processes to account for those issues.
“If you just approach quality improvement as an engineering model and you don’t change culture, it’s not sustainable and it’s too resource intensive,” says Pronovost. “We combined the effort to reduce bloodstream infections with an effort to improve teamwork and communication using CUSP.”
Pronovost says he and his colleagues at JHU realized that taking the CUSP model to other facilities and allowing for flexibility when encouraging culture change would help their program flourish. The technical, scientific aspects of preventing CLABSI are going to be the same at each facility, but it’s necessary to leave the reorganization of culture components up to each facility to design the best functioning systems, says Pronovost.
Keys to a successful program
The original MHA and JHU project was successful because of the following:
- Use of checklists. Pronovost calls checklists “democratized knowledge” because they make every staff member aware of what exactly needs to occur. “We took a 100-page guideline from the CDC and called out five clear, unambiguous things to do [to prevent infections],” says Pronovost. These were:
- Wash your hands with soap
- Clean the patient’s skin with clorhexadine antiseptic
- Put sterile drapes over the patient’s body
- Wear a sterile hat, mask, gloves, and gown
- Apply sterile dressing once the central line is inserted
- Provision of valid feedback and measurement of infections. If any team involved in the project did not submit data, its CEO got a phone call from JHU asking for the data or requesting that team to drop out of the program, says Pronovost. It’s impossible to measure whether a quality improvement program is succeeding without good data. “I said, ‘You either commit to do this, or bug off,’ and nobody bugged off. We raised the bar,” he says.
- A focus on culture and teamwork. “Teamwork is the lubrication that allows for good system design,” Pronovost says. Part of this project was transforming the culture within those facilities to empower staff members to speak up when they saw that another staff member was not completing all parts of the checklist. By presenting the cause as being larger than one person or position, this thinking prevailed.
- Commitment to safe care as a right, not a competitive advantage. This ideal was key to this program functioning, says Pronovost. “If your rates are down, that’s great, but then go call your partner hospital and help them. Success is [measured by] the rates of infections in this state, not just in this hospital,” says Pronovost about the attitude he and his colleagues instilled in participating facilities.
Goals for the next three years
Although the primary goal is to eliminate CLABSI, Pronovost says other goals for the next three years include advancing the science of quality improvement by creating new models, building capacity to bring hospitals and states together to work on quality improvement projects, and putting joy back into clinicians’ work. However, these goals depend on building a culture of safety with each participating organization.
“Building the relationship and trust with the hospital associations or doctors, [showing] that we have no hidden agenda, that we’re simply out for high-quality care, takes time,” Pronovost says.