North Carolina Eliminating Methicillin-Resistant Carolina Eliminating Methicillin-Resistant...

1N o r t h C a r o l i n a E l i m i n a t i n g M e t h i c i l l i n - R e s i s t a n t S t a p h y l o c o c c u s a u r e u s

Developed by the North Carolina Center for Hospital Quality and Patient Safety, PO Box 4449, Cary, NC 27519-4449

www.ncha.org/ncchqpsSeptember 2007

The materials in this tool kit can be reproduced for the purpose of improving infection prevention processes in a hospital or healthcare organization, but cannot be reproduced with intentions of commercial use.

Nor th Caro l ina E l iminat ing

Meth ic i l l in -Res is tant Staphylococcus aureus

(MRSA)

T O O L K I T©

2 N o r t h C a r o l i n a C e n t e r f o r H o s p i t a l Q u a l i t y a n d P a t i e n t S a f e t y

A c k n o w l e d g e m e n t s

Thanks to those that have shared their time and expertise to help develop and produce thistool kit. It is through their expertise, creativity and generosity of sharing their knowledgethat we have been able to produce this tool kit.

Specifically, thank you to:

Terri Bowersox, BSIE, MBA, FACHE Director, Performance Improvement VHA Central Atlantic 521 E. Morehead Street, Suite 300 Charlotte, NC 28202

The Statewide Program for Infection Control andEpidemiology (SPICE)CB# 7030, Bioinformatics 2156130 Mason Farm RoadUniversity of North Carolina School of MedicineChapel Hill, N.C. 27599-7030

The following NC Center for Hospital Quality and Patient Safety staff were involvedin writing the tool kit:

Carol Koeble, MD, MS, CPEDirectorNC Center for Hospital Quality and Patient SafetyVice PresidentNorth Carolina Hospital AssociationCary, NC

Barb Edson, RN, MBA, MHAQuality and Patient Safety ConsultantNC Center for Hospital Quality and Patient SafetyCary, NC

Cover Design and artwork by Dale Design, Cary, NC


Chapter 1: Introduction

Chapter 2: The Project

Chapter 3: The Team and Communication

Chapter 4: Performance Improvement

Chapter 5: Measurement

Chapter 6: Spreading and Formalize

Chapter 7: Reference Materials

T a b l e o f C o n t e n t s


In 2003, 63-year-old Marion Costa was rushed to the hospital for treatment of a life threatening gastrointestinalbleed. She received two pints of blood before being moved to the ICU and then to a step-down unit when hercondition stabilized. The Heparin IV Lock (Heplock) used by hospital staff was left in her arm as a precautionarymeasure in case she need additional blood transfusions in the ICU and dated for removal in three days.

Three days later Marion developed severe headache, backache and leg pain. She became disoriented andspiked a fever that went up to 105 degrees. Her doctor had to put her to sleep for pain control and she awoke36 hours later having no idea what happened to her. She had been cultured and diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) and was put on Vancomycin and other antibiotics to treat the infection.Her primary care physician visited her a few days later and Marion complained of pain and stiffness in her upperarm. Her doctor took one look at the outdated Heplock that was still in her arm after six days and told her thatnow he knew the source of her infection. He ordered tests that morning and found phlebitis in the artery wherethe expired Heplock had been inserted.

But that was just the beginning of Marion's hospital infection ordeal. A week later severe gastrointestinal bleedingresumed and she was diagnosed with a C-difficile, which caused inflammation of her colon and diarrhea. Again,she required more blood transfusions. Within the week, she was discharged to a nursing home to continue herantibiotics treatments for her MRSA infection. After one week at the nursing home she began running another highfever and a few days later was transferred by ambulance back to the hospital. She was diagnosed with a gramnegative blood infection, which was found lodged in the PICC line used for administering her antibiotics. Marionwas treated with eight different antibiotics to treat the blood infection.

Marion considers it a miracle that she survived her hospital infection nightmare. She remains angry that her lifewas endangered by the poor infection control practices she observed during her hospitalization.

I n t r o d u c t i o n1

Marion Costa, Red Bank, NJ

Story reprinted with permission from Marion Costa,the author. Story appears on Consumers Unionwebsite, http://www.consumersunion.org


T h e P r o b l e mHealthcare-associated infections (HAIs) are a major cause of morbidity, mortality and excessive healthcare costs. Basedon the best available data the Centers for Disease Control and Prevention (CDC) estimates nearly 2 million HAIs occurin U.S. hospitals and 99,000 people die as a result of these infections annually. There are approximately 4.5 HAIsper 100 hospital admissions, 9.3 infections per 1000 patient days in the intensive care unit and 2 surgical siteinfections per 100 operations. HAIs cost between 5-6 billion dollars annually, with an average additional incrementaldirect cost of $8,832 per patient. 1,2

Staphylococcus aureus is a major cause of infections in both the hospital as well in the community. S.aureus is a gram-positive, opportunistic bacterium that colonizes the skin. It is present in the nares of approximately 25-30% of healthypeople. Depending on its intrinsic virulence or the ability of the host to ward off infections, S.aureus can cause arange of infections in humans including superficial skin lesions such as boils; more serious infections such aspneumonia, mastitis, phlebitis, meningitis, and urinary tract infections; and deep-tissue infections, such as osteomyelitisand endocarditis.3 S. aureus is a major cause of HAIs reported to the National Nosocomial Infections Surveillance(NNIS) System, including surgical site infections (SSI), ventilator-associated pneumonias (VAP) and catheter-associatedblood stream infections.4

Infections with methicillin resistant Staphylococcus aureus (MRSA) are especially problematic because they are resistantto the usual antibiotics (penicillin, amoxicillin, oxacillin and methicillin) used to treat them. Antibiotic resistance inS.aureus emerged in the 1940s when penicillin use was common. Over the next two decades resistance to penicillinand the newer semi-synthetic pencillinase resistant agents became wide spread. Within six months after the marketingof methicillin in 1960, resistant isolates were reported. Since then methicillin resistant S.aureus has spread worldwide.In 1997 resistance to vancomycin, the last commonly used antimicobial agent for which S.aureus was uniformlysubsceptible to, emerged.5,6

A recent report by the Agency for Healthcare Research and Quality (AHRQ) reviewed data from the Healthcare Costand Utilization Project (HCUP) to analyze the trends and impact of MRSA. Hospitalizations associated with MRSAincreased tenfold between 1995 and 2005; more than tripled from 2000 to 2005; and increased 30 percent from2004 to 2005. In 2005 approximately 368,600 hospital stays were for infections with MRSA. Hospital dischargeswith a diagnosis of MRSA were 0.7%. The length of stay for MRSA hospitalization was more than doubled whencompared with all other stays, 10 days versus 4.6 days respectively. Hospital costs are increased with MRSAhospitalizations. On the average MRSA hospitalizations cost $14,000 compared to $7,600 for non-MRSA stays. In-hospital mortality was more than double for MRSA patients over non-MRSA patients. The in-hospital death rate was4.7 percent for MRSA stays compared to 2.1 percent for all other hospitalizations. Over 5,000 patients die as aresult of these infections.7

• CDC estimates nearly 2 million healthcare acquired infections occur in US hospitals and 99,000 peopledie annually.

• Healthcare acquired infections cost between 5-6 billion dollars annually, with average incremental cost$8,832.00 per patient.

• S. aureus is a major cause of HAIs reported to the National Nosocomial Infections Surveillance (NNIS) System.• Hospitalizations with methicillin resistant Staphylococcus aureus (MRSA) increased 10 fold between 1995 and 2005.• The length of stay for patients with methicillin resistant Staphylococcus aureus (MRSA) was 5.4 days longer than

those patients without MRSA. • On the average methicillin resistant Staphylococcus aureus (MRSA) hospitalizations cost $14,000 compared to

$7,600 for non-MRSA stays. • Over 5,000 patients die annually as a result of methicillin resistant Staphylococcus aureus (MRSA) infections.


Source: AHRQ, Center for Delivery, Organization and Markets, Healthcare Cost and Utilization

Project, Nationwide Inpatient Sample 1993-2005

The statewide MRSA infection rate for North Carolina hospitals is unknown. The Centers for Disease Control estimatesMRSA infections in hospitalized patients account for 3.95 per 1,000 discharges (0.4 percent).8 The ARHQ, using2006 discharge data, found a rate of 7.48 per 1000 discharges (0.75 percent) for both hospital MRSA and CA-MRSA. Using discharge data9 for North Carolina non-VA, acute care hospitals an estimated 4,345 - 7,701 MRSAinfections occurred in hospitalized patients during 2006. Based on the direct hospital costs in the AHRQ report thisresults in $27.7- $49.8 million additional costs for NC hospitals.


T h e S o l u t i o nHospitals in the US and other countries have taken aggressive action to reduce MRSA infections acquired duringhospitalization. In Denmark, the prevalence of MRSA peaked at approximately 18% among all S. aureus isolates (andapproximately 30% among blood isolates only) at the end of the 1960s, then regularly decreased during the 10following years. This decrease has been attributed to various interventions, including screening of high-risk patients andhealthcare workers, barrier precaution, enhanced environmental cleaning, hand hygiene awareness, pre-emptiveisolation of high-risk carriers and decolonization of carriers. Since the beginning of the 1980s, the percentage ofMRSA has remained extremely low, and below 1% among blood S. aureus isolates. Except for a very small number oflocalized hospital outbreaks, Danish MRSA isolates now represent imported cases from countries with highprevalence.10

In the U.S. many organizations and regional networks have implemented similar interventions to reduce hospitalacquired MRSA. At the Brigham and Women's Hospital in Boston, Huang focused efforts in the intensive care unit(ICU). Over an eight-year period several interventions were implemented including barrier precautions, hand hygienepromotion, contact precautions and active surveillance cultures. The rate of MRSA bloodstream infection decreased75% in the ICU.

Two organizations in Pittsburgh, Pennsylvania, the VA Pittsburgh Health System (VAPHS) and the University of PittsburghMedical Center Presbyterian (UPMC-P) collaborated to control MRSA. Following implementation of a bundle ofinterventions (standard precautions, hand hygiene, active surveillance cultures, contact precautions and culturalchanges) VAPHS saw a 70% decrease in MRSA infection on one unit. At UPMC the rate of hospital acquiredinfections decreased 90% with implementation of active surveillance for all patients admitted to the ICU, weekly culturesfor ICU patients and standard precautions for all positive patients.11

A rational strategy for reducing MRSA infections is to prevent transmission. Person-to-person transmission of MRSA,either directly or indirectly, constitutes the major route of transmission and dissemination. Staff may acquire MRSA ontheir hands, clothing or equipment while taking care of infected or colonized patients. If recommended precautions arenot followed staff may transfer MRSA to other patients, who then become colonized and at risk for infection. Disruptionof this cycle requires recognition of the sources of MRSA (patients, staff, the environment) and the consistent use of handhygiene, physical isolation, barriers, personal protective equipment, dedicated equipment and environmental measuresto prevent the contamination of healthcare works and the transmission of MRSA to other patients and staff.

Recommended Strategies to Reduce MRSA Infections• Hand hygiene• Decontamination of the environment and equipment• Dedicated equipment• Active surveillance cultures• Contact precautions for colonized and infected patients• Cultural change• Device Bundles (Central Line and Ventilator)


N a t i o n a l S u p p o r t a n d A l i g n m e n tMany national healthcare improvement initiatives and requirements are in alignment with preventing, reducing andeliminating healthcare-associated infections. The Institute of Medicine (IOM), the Institute for Healthcare Improvement(IHI), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid (CMS), theJoint Commission, the Hospital Quality Alliance, the National Surgical Care Improvement Project (SCIP), the Centers forDisease Control and Prevention (CDC), the National Quality Forum (NQF) and the National Patient Safety Foundationall have aims and/or requirements that focus on HAIs.

Table 1: Alignment with National Initiatives12


R e f e r e n c e s :1. Cardo, Denise. Comments to the US House of Representatives on the CDC's Role in Monitoring and Preventing

Healthcare-Associated Infections. 03.29.06 Accessed 01.04.07 fromhttp://www.hhs.gov/asl/testify/t060329.html.

2. Murphy, D and Whiting, J. Dispelling the Myths; The True Cost of Healthcare-Associated Infections. APICBriefing, February 2007.

3. Keuhnert, MJ et al. Methicillin-resistant Staphylococcus aureus Hospitalizations, United States. Emerg Inf Dis2005;11(6):868-872

4. Todar, Kenneth. Todars's Online Textbook of Bacteriology. 2005. Accessed 10.07.07 from http://textbookofbacteriology.net/staph.html.

5. Ibid. Keuhnert, MJ et al.6. Grundmann, H et al. Emergence and Resurgence of Methicillin-resistant Staphylococcus aureus as a Public-health

Threat. Lancet 2006;368:874-857. Elixhauser, A and Steiner, C. Infections With Methicillin-Resistant Staphylococcus aureus (MRSA) in US Hospitals,

1993-2005. ARHQ Statistical Brief #35. July 20058. Ibid. Keuhnert, MJ et al.9. Solucent discharge data 2006.10. Muto, C. Controlling Methicillin Resistant Staphylococcus aureus presentation for VHA Accelerating Improvement

Network: Eliminating MRSA. Oct 2006.11. Getting Started Kit: Reduce Methicillin-Resistant Staphyloccous aureus (MRSA) Infection How-to Guide. Institute for

Healthcare Improvement. 2006. Downloaded on 01.04.07 fromhttp://www.ihi.org/IHI/Programs/Campaign/MRSAInfection.htm.

12. 5 Million Lives Alignment with National Health Care Improvement Initiatives table. Version 8 May 2007.Accessed on 10.07.07 from http://www.ihi.org/NR/rdonlyres/CC960DDD-2BB3-41C1-9D56-B957876C9C1B/0/CampaignAlignmentWithNationalHealthcareImprovementInitiatives.pdf

2T h e P r o j e c t


T h e P r o j e c t 2Experts at the Institute of Healthcare Improvement (IHI) list “Will”, “Ideas” and “Execution” as the factors that facilitateimprovement. These factors work together to achieve improvement. “Will” must come from the senior leaders to thedirect care providers. “Ideas” must come from those doing the process. “Execution” must incorporate both the “Will”and the “Ideas” to produce the change we call improvement. To “Execute“ the steps necessary to improve a process, itis important to have a basic understanding of what a project is and how to manage a project successfully. Projectknowledge will help you plan, track, and communicate to others about your project. It will also help you navigatepotential barriers. While we think in terms of projects and project management in the sense of constructing a buildingor bringing a new product to market, we can also draw parallels to healthcare process improvement. This chapter isdesigned to give you a basic level of understanding of a project and project management, and to assist you inapplying some of those concepts to your project.

P r o j e c t A project is a temporary endeavor undertaken to create a unique product or service, which brings about a beneficialchange or added value.1 The project is completed when the objectives are reached or it is clear that the objectives willnot or cannot be met, or there is no longer a need for the project and the project is terminated.2 It is important tocommunicate with others the characteristics of a project so they can have a clear understanding of expectations. Thecharacteristics of a project are that it is temporary, unique and has progressive elaboration.

1. Temporary A project has a beginning and an end. A project is different from processes, or operations, which are permanent orsemi-permanent, with ongoing functional work to create the same product or service over and over again.3 The purposeof the project is to attain its objective and then to terminate, whereas the objective of processes or ongoing operationsis to sustain the business.4 In hospital quality and patient safety, the project is usually to improve or make safer analready existing service or process, based upon scientific evidence. Therefore, the improvement project itself istemporary, and the process that was improved is permanent or semi-permanent. Making a clear distinction betweenthe project and the processes we are trying to improve assists us in planning by securing the appropriate resources andcommunicating our project needs to others. It is far easier to ask a busy physician or nurse to assist on a project teamthat will have a beginning and an end, rather than to work on an on-going permanent or semi-permanent team.

2. UniquenessThe uniqueness of a product or service originates from the fact that each organization is different. In the case of ahospital, services may be similar from hospital to hospital, but the processes that they employ to deliver the service maybe very different. The environment that they provide the service, their resources (financial, technological and human),their organizational structure and their culture may vary. Therefore, the purpose of improvement projects using theModel for Improvement (discussed in a subsequent chapter) is to develop or revise processes tailored to the hospital'sunique environment that will achieve the best and safest patient care based on scientific evidence. There is not a one-size-fits-all solution for process improvement across hospitals.


3. Progressive Elaboration A project's scope is often described broadly and then further defined as the project progresses and the project teamlearns more about the process and steps necessary to improve the process.5 In the case of a hospital qualityimprovement project, the scope may first be described as evidence-based process necessary to achieve the outcome.For example, a component of care in preventing the transmission of MRSA is to correctly wash your hands prior topatient contact and after patient contact. The team knows the steps necessary for correct hand washing and puts thisin their project scope; but as the team learns more about the process, they realize that there are not sinks readilyavailable in all the patient care areas. So the team meets with the maintenance department to plan renovation toincorporate sinks in the areas.

P r o j e c t M a n a g e m e n tProject management is the discipline of organizing and managing resources (i.e. people) in such a way that the projectis completed within defined scope quality, time and cost constraints.6 As defined by A Guide to the ProjectManagement Body of Knowledge 3rd edition (PMBOK), project management is the application of knowledge, skills,tools and techniques to project activities to met project requirements.7

Hospitals tend to be organized in a functional structure that is organized by specialty, such as respiratory, nursing,pharmacy, physical therapy, nutrition, etc. They can further be subdivided into other functional structures such aspediatric nursing service, or operative nursing service, etc. They tend to be hierarchal in nature and have staffmembers that directly answer to one supervisor. However, the processes that they engage in to deliver care often goacross functional units. Therefore, projects that involve developing or refining processes need cross-functional teams.While most hospitals have quality improvement departments to work with the cross-functional teams, they are working inan organization that is non-project based and lacking in management systems to support projects effectively.

Figure 2.1: Hospital Organizational Structure and Processes

Contrary to functional organizations, highly projectized organizations have systems in place to assist the projectmanager. The project manager in a projectized organization has a great deal of authority and independence.8 Sincehospitals tend to be toward the functional organizational end of the spectrum, it is important to equip the project teamwith skills, knowledge, tools and techniques to organize and manage resources. The fundamental project managementconcepts are project processes, life cycles, milestones, management systems and stakeholders. There are other termsthat are in the glossary at the end of the tool kit that are important to define but not necessary to elaborate on.

Project Processes Project management requires coordinating a series of project processes, the “how” we are going to do somethingtoward a common goal, the “what” we are trying to do. 9 These processes are the smaller steps necessary to produceyour goal. In the project management world, these are broken down into five different process groups: initiating,planning, executing, controlling and closing. In a hospital quality improvement project, an initiating process maybe thesenior leader requesting improvement in a quality indicator. To do so a preliminary aim statement (discussed insubsequent chapter) is developed, a project team is formed and a project plan is drafted in the planning phase. In the


executing phase, the team works on the deliverables necessary to accomplish the change. For example a deliverablemay be a new process or new physician order set to assure surveillance cultures are obtained, etc. During this phase,using the Model for Improvement, a process will be developed or refined and tried with the different segments. Themonitoring or controlling phase is where the team would measure their progress. The final phase is the closing phase,and it is during this phase that the project is closed out. In hospital quality improvement, the closing phase is when thefinal tested process is closed and the process is turned over to operations.

Project Life Cycle Project life cycle refers to the stage or timing that your project is in at any given time. They are broken down into fourphases, concept, planning, execution and closeout. Using these broad phases helps to assure that the team and thepeople that the team communicates with are aware of where they are in the project. They tell everyone exactly wherethe project team is in the project.

Project Milestones Project milestones are key events of the project. They do not represent an activity or a resource per se but represent amajor marker for the success of your project. The project milestone may indicate a completion of a phase or thecreation of a prototype. For example, in a hospital quality improvement project this may be completion of a phase orcompletion of process testing

The Project Management SystemsProject management systems are a family of interrelated components that work together to support the project.10 Theyare categorized into seven components: human, cultural, organizational, methodological, informational, planning andcontrol/management. Human components deal with people issues; cultural components deal with the beliefs andvalues of the hospital; methodological are the software or tools used to track the project; informational is the componentthat tracks information about the project (for example PDSA worksheets); planning outlines the project plan; and finally,control and management means having authority to actually get things done. The most crucial element to have inproject management is people skills.

Project Stakeholders A stakeholder is a person, or more typically a group of people (represented by a person or a team) that has a vestedinterest in what your project is doing.11 There are many stakeholders in hospital quality improvement ranging from thoseat the blunt-end to those at the sharp-end, including the patient. The project sponsor is an important stakeholder in theproject and will be discussed in more detail in the next chapter.

M a n a g i n g y o u r p r o j e c t Now that you have a fundamental understanding of a project and project management, it is time to address yourproject. Two of the most important elements of an effective project are a clear plan to determine resources required anda realistic schedule. You may want to ask yourself the following questions:

• What elements of project are we going to focus on? For example, hand washing, surveillance cultures, barrier precautions, etc.

• How many resources are available to conduct this project? Who within the hospital is available to work on this project?

• When do I need to have the process in place?


As discussed above, your project is unique to your facility. It is dependent on where and how you receive yourcustomers. It is also dependent on your current systems, size, culture and adaptability. All these factors determine thenumber of tests of change and how quickly a project plan can be implemented. In the first six weeks of the project, youwill understand your current process, develop ideas to change or create a new process, and perform some tests ofchange.

In addition to reviewing project processes, the team will need to identify the milestones for the project. The team willneed to account for the interrelationships of the project management systems as they plan their project.

Table 2.2 Project Process Guide


R e f e r e n c e s :1. http://en.wikipedia.org/wiki/Project_management2. A Guide to Project Management Body of Knowledge (PMBOK® Guide) Third Edition © 2004 Project

Management Institute, Four Campus Boulevard, Newton Square, PA 19073-3299, p.5. 3. http://en.wikipedia.org/wiki/Project_management4. A Guide to Project Management Body of Knowledge (PMBOK® Guide) Third Edition © 2004 Project

Management Institute, Four Campus Boulevard, Newton Square, PA 19073-3299, p. 7. 5. Ibid, p.6. 6. http://en.wikipedia.org/wiki/Project_management7. A Guide to Project Management Body of Knowledge (PMBOK® Guide) Third Edition © 2004 Project

Management Institute, Four Campus Boulevard, Newton Square, PA 19073-3299, p. 8. 8. Ibid, p.29. 9. Project Management 101© Jason Kaira, http://www.suite101.com/lesson.cfm/17517/890/210. Project Management 101© Jason Kaira, http://www.suite101.com/lesson.cfm/17517/890/711. Project Management 101© Jason Kaira http://www.suite101.com/lesson.cfm/17517/891/4

3T h e T e a m a n d

C o m m u n i c a t i o n


T e a m s a n d C o m m u n i c a t i o n 3Project management is 99% about managing people, and the project team is directly responsible for the success of theproject. Skills such as communicating, coaching, negotiating, leading, facilitating, and resolving conflicts are allimportant to the team's success.

Who are the best people to work on the project team? While a dedicated project team, including the direct careproviders, is desirable to conduct the performance improvement project, the resources are not usually available to dothis. The team leader initially may need to devote more time than other members of the team to facilitate the project.Additionally, it is important to estimate resource consumption of other team members to ensure the clear expectations oftime commitments.

Te a mTeamSTEPPS™, an evidence-based system developed by the Department of Defense (DoD) in collaboration with theAgency of Healthcare Research and Quality (AHRQ), defines a team as two or more people who interact dynamically,interdependently, and adaptively toward a common and valued goal, have specific roles or functions, and have time-limited membership.1 An effective project team will include representatives from every phase of the process, acrossfunctional groups. For active surveillance in the MICU, the team may include the MICU nurse manager, MICU staffnurses, a lab professional, the infection control practioner (ICP), the health unit coordinator (unit secretary) and theintensivist. To ensure that the process can spread successfully in your organization, it is also important to includerepresentation from quality improvement or another hospital professional that will address the organization as a whole.

Additionally, a project sponsor, a very important stakeholder, should be identified. A project sponsor is a person whois responsible and accountable to his/her organization for the performance and results of the project improvementteam.2 This person is not a member of the team who is actually working on the steps necessary to improve the process,but is the person responsible for securing the resources (i.e. paying for it). The project sponsor role has not often beenwell defined, but they have attributes and responsibilities and can employ strategies to help the team.


In addition to having diverse professionals on your team, you will want to identify the roles of the team members. Thismay be based on their skills inventories. Successful project teams have identified team responsibilities and roles. Rolesinclude a team leader or facilitator, a recorder and a meeting time-keeper, data collector, etc. You may choose toassign a task based on profession or duties. At the end of this chapter, there are tools to help with recording skillsinventories and assigning team roles and tasks.

Table 3.1 Project Sponsor Characteristics13


The project team is responsible for a variety of duties. Highlights of some of these project duties include:

There are many barriers to effective team performance. The most common are lack of time, clear aims, communicationand team leadership. TeamSTEPPS™ does recognize the attributes of high performing teams see Table 3.2.

Table 3.2 High Performing Teams Team Attributes - Adapted from TeamSTEPPS™3

• Planning - Determining the scope of the project based on available resources and planning project tasks• Selecting the Project Location and Communication - Determining where the pilot or test project will be done,

gathering of initial baseline information, deciding how the project will be communicated, and deciding who willbe responsible for the communication that is carried out

• Selecting and Testing Change Ideas (PDSA)- Reviewing the data, making recommendations for process changes andassuring that the changes are tested effectively

• Collecting Data - Assigning responsibility to individual(s) for data collection• Spreading New Process - Developing spread plan, including education and communication • Formalizing Process - Assigning responsibility to an individual(s) to formalize process in the organization


Successful teams also employ mutual supportive behaviors, sometimes referred to as “back-up behaviors.”4 These mutualsupport behaviors help teams foster a shared mental model, allow for adaptability, and provide team orientation andmutual trust.5 Mutual support tools that can be employed to foster project teamwork are task assistance, feedback,assertion, DESC script and collaboration, table 3.3.

The project team leader is crucial to the team. Effective team leaders, according to TeamSTEPPS™, are able to organizethe team, articulate clear goals, make decisions through collective input of members, empower members to speak-upand challenge when appropriate, actively promote and facilitate good teamwork, and resolve conflicts skillfully.7 Ateam leader is a well-informed team member who makes decisions and takes action.8 They are able to delegate toothers and communicate clearly their expectations, “what” they want done, and “who” they want to do it.

Table 3.3 - Mutual Support Tools - Adapted from TeamSTEPPS™6

Team Meetings and Other Team Tools The project team meetings should be considered sacred time and used as a time to brainstorm, discuss findings, assigntasks and assure a common direction. Some teams choose to do meetings electronically or over the telephone. If teammembers find the meeting valuable, they will continue to attend. Therefore, the team should strive to use meeting timeas effectively and efficiently as possible. Regardless of how you decide to conduct your regularly scheduled teammeetings, you should use agreed-upon ground rules.

In addition to team meetings, the team may use other TeamSTEPPS™ tools such as the Brief, the Huddle or the Debrief,Table 3.4. While these tools were developed for a patient care team, the tools can also be used by a project teamduring PDSA cycles.

C o m m u n i c a t i o nCommunication is the response you get from the message you sent regardless of its intent- author unknown. Early andfrequent communication within and outside the project team, is essential to the success of any quality improvementproject. Communication within the project team is an important component of the team process because it serves as acoordinating mechanism or supporting structure of teamwork.10 Communication outside the project team must target aspecific audience and include education on the problem and the solution.

Internal (project team) communicationEffective communication exchange, according to TeamSTEPPS™, involves sending, recurring, verifying and validatingtechniques. These techniques help assure that the message that was intended was received. Sending techniques seekinformation from all available sources, recurring techniques involve analyzing the information provided andsynthesizing, verifying techniques involve checking back information to assure intent of sender, and validatingtechniques confirm the intent of the sender. TeamSTEPPS™ tools used to improve communication among health careteams, taking care of patients, can be adapted and used in communication among project teams, Table 3.5


Table 3.4 Team Tools - TeamSTEPPS™9


External communication - Engaging others Leadership is paramount in setting and communicating the vision for the entire organization. John P. Kotter, a well-knownauthor and Harvard business professor, wrote in his book Leading Change that “leadership should estimate how muchcommunication of the vision is needed, and then multiply that effort by a factor of ten” (Kotter, 1996).12 Therefore,early engagement of senior administrative and physician leadership is one of the most important determinants forproject success.

The methods of communication and education can be verbal and/or written and should be targeted to theadministrative audience. It should convey a concise message outlining the problem, healthcare acquired infection -specifically MRSA, and the impact on your hospital. It should convey the solution, such as hand washing, barrierprecautions and active surveillance. When examining costs and benefits, it is important to keep in mind the foursectors of the hospital's business: financial, customer, learning and growth (employee development), and the internalbusiness (mission, service or product). While all four quadrants of the hospital business are important from theleadership perspective, they may have a greater-perceived obligation to the financial aspects of the hospital business.Therefore, your message should be delivered with great emphasis on financial costs. Tools at the end of this chaptercan assist you in communicating the message to the senior leadership.

The financial costs of developing or revising a new process and implementing it can be broken down into two parts.The first part is the project costs. These are the costs associated with establishing a team, running pilot projects to testand tweak the process, educating the various stakeholders, purchasing items that you may need to run the pilots andlater, spreading and formalizing the process so it is incorporated into routine operations. This tool kit offers a samplewhite paper proposal to help you estimate project costs. It does not address operational costs. These costs arebeyond the scope of the tool kit and vary greatly depending on your organization.

Table 3.5- Communication Tools - TeamSTEPPS™ 11


The second part of the financial costs associated with your new or revised processes to eliminate MSRA is the costs ofon-going operations, the non-project costs. To determine these costs, you must have an understanding of who will beresponsible for each step of the process, how much time each step will require, and the other non-human resources thatmaybe required, such as lab tests, availability of equipment and supplies. It is important to note that many hospitalshave implemented processes to eliminate MRSA into routine operations with little additional resources. To do so, theseorganizations have carefully assessed their current processes, eliminated steps that are no longer needed and beencreative in addressing their barriers. You can hypothesize what this may look like for your hospital, based on similarhospitals' strategies and added costs.

To balance expenditure, it is necessary to examine the benefits of the improvement project. The data collected in thisproject can assist you by comparing the number of healthcare acquired infections, or specifically MRSA infections, priorto the implementation of processes to eliminate MRSA and after implementation of new processes. Comparing thelength of stay (LOS) of patients prior to the implementation of the new processes and then after implementation can berecorded. The financial costs can then be estimated. Some may argue that tying these indicators to financial costs isa stretch. However, the financial cost of care will be reduced if your process allows you to deliver better, moreefficient and safer care. Until your team collects data for several months, however, documenting the benefits may bedifficult. In the meantime, you may project the benefits by applying your hospital's financial data to outcomes inpublished studies. The business case for eliminating MRSA is highlighted in Chapter 1.

Many physicians are very knowledgeable about the evidence of the care processes to prevent infection, but arefrustrated that they are not able to accomplish them consistently for their patients. Often times they must change theirprocesses, sometimes adopt new ones that seem far too complex and they still are not achieving reliable care for alltheir patients. The new processes that are adopted should be designed to reduce workload if at all possible. Instanding orders, eliminate steps if possible, and fit into the regular workflow. As with senior leadership engagement,physician engagement is very important to the success of your project. If there is a physician leader that is also a senioradministrative leader, it is recommended to ask her/him to champion this effort. In any case, identifying one or morephysician leaders - either formal leaders or respected “thought leaders” - to champion the initiative will make your effortsmuch easier.

In targeting physicians, a concise message in many different formats and venues will be important. Most physicians intoday's environment are feeling overwhelmed. A message that conveys the importance of preventing MRSA infectionsto the safety of their patients should be emphasized. It will be important to deliver a balanced message that stressesthat the aim of the Eliminating MRSA project is not to question their practice. Rather it is to build a system that assuresthat the patient receives exactly the care he/she should receive every time. Assure the physicians that they are a veryimportant part of this safety process for the care of their patients.

Sharing the outcome data, such as MRSA infection per 1000 patient days, or the decrease in the number of centralline or ventilator associated pneumonia (VAP) infections, etc., can assist you in helping build the case for the eliminatingMRSA care processes. Until your hospital data is available, you may need to share study data with the physicians.But perhaps the most effective and inspiring way to evoke change is to share the individual stories of patients with thephysicians. The physician is the key player in this initiative and therefore must be involved in developing a process thatworks.


As with educating the senior leadership and physicians, communication with the staff is very important. The staffmembers, like the physicians, will need to participate in process development. They are the keys to the success of theteam, as they will be involved in some portion of the eliminating MRSA care processes. A clear understanding of theeliminating MRSA care processes and what their contributions to the processes are very important.

In targeting the message to staff, you will need to keep in mind that they, like physicians, are inundated with tasks andresponsibilities. Asking them to learn about a new program, let alone participate in a pilot project or development ofthe process, may seem too much for some. Therefore, the message to the staff members will place a great emphasis onthe enhancement of their work environment and care and service delivered to their patients. It will be important todeliver a balanced message that stresses the aim of eliminating MRSA care processes is not to question the care thatshe/he has been delivering, or to take over her/his responsibilities to their patients, but rather to put a safety net inplace to assure that all patients are given all the appropriate evidence based care processes for the best outcomesevery time.

It is also important to communicate to the staff members that while this may seem like more time on the forefront to meetthe eliminating MRSA care processes, they must look at it from the standpoint that using these processes can actuallyreduce length of stay and complications.

Studies can be shared with this group until outcome data becomes available. Once the outcome data, such as MRSAinfection per 1000 patient days, becomes available, even in the pilot group, it should be shared with all staffmembers. Printing your online run charts of the process measures will assist you as you communicate your progressduring the project. As with physicians, sharing specific patient examples (stories) can be a very powerful motivator.

Patients can and should play a major role in the eliminating MRSA. The patient has the ability to verify with their careproviders if they have received care that will eliminate their chances of acquiring MRSA. Education andcommunication with patients and families to explain the purpose of the elimination of MRSA care processes and theirrole in these processes. There are tools within this kit that will assist you in communicating with patients.

To effectively lead change, we must communicate our message again and again and again. We may start to think thateveryone already knows what we are going to say because we have shared it so many times before. According toKotter in Leading Change, “the most carefully crafted messages rarely sink deeply into the recipient's consciousnessafter only one pronouncement. Our minds are too cluttered, and any communication has to fight hundreds of otherideas for attention…effective information transferal almost always relies on repetition.” (Kotter, 1996).13 Communicationinforms all audiences of why the effort is important and invites participation. Common communication methods arenewsletters, posters in common areas, staff meeting agenda items, and face-to-face meetings. There are examples of acommunication newsletter, poster and a communication checklist at the end of this chapter. Additionally, there is apower point slide presentation to help communicate your message. The presentation can be adapted to a specificaudience (leadership, physicians, pharmacy/nursing staff) by removing or revising slides.


R e f e r e n c e s :1. TeamSTEPPS™, Department of Defense (DoD) Patient Safety Program and Agency for Healthcare Research and

Quality, http://dodpatientsafety.usuhs.mil/index.php?name=News&file=article&sid=312. Provost, L., Lewis, A., Role of the Improvement Team Sponsor, Impact Series, ppt., IHI, July 12, 2007.3. TeamSTEPPS™, Department of Defense (DoD) Patient Safety Program and Agency for Healthcare Research and

Quality, Instructor Guide, Team Structure, 06.1, p.6-7. 4. Ibid, Mutual Support, 06.1. p.4. 5. Ibid, Mutual Support, 06.1, p.4.6. TeamSTEPPS™ Pocket Guide, Department of Defense (DoD) Patient Safety Program and Agency for Healthcare

Research and Quality, p.20-22, 25-26.7. Ibid, p.9. 8. TeamSTEPPS™, Department of Defense (DoD) Patient Safety Program and Agency for Healthcare Research and

Quality, Instructor Guide, Leadership, 06.1, p.39. TeamSTEPPS™ Pocket Guide, Department of Defense (DoD) Patient Safety Program and Agency for Healthcare

Research and Quality, p.10.10. TeamSTEPPS™, Department of Defense (DoD) Patient Safety Program and Agency for Healthcare Research and

Quality, Instructor Guide, Communication, 06.1, p.2.11. TeamSTEPPS™ Pocket Guide, Department of Defense (DoD) Patient Safety Program and Agency for Healthcare

Research and Quality, p.28-31.12. Kotter, J. P., Leading Change, Harvard Business School Press, 1996. 13. Ibid.

4P e r f o r m a n c e

I m p r o v e m e n t


P e r f o r m a n c e I m p r o v e m e n t4As discussed in chapter one many national healthcare improvement initiatives and requirements are in alignment withpreventing, reducing and eliminating healthcare-associated infections (HAIs). These initiatives and requirements offervaluable insight into how well your hospital is providing the care processes it should be providing to prevent, reduceand eliminate HAIs. Based on this knowledge most hospitals are working hard to improve these infection preventionprocesses. But is just hard work and diligence enough for a hospital to reliably provide the right care every time toevery patient?

In this chapter you will learn how to assess your current processes relating to eliminating MRSA infections; how to moveyour current processes to a 95% level of reliability; and gain knowledge of tools that can help you reach your goal.

A s s e s s i n g t h e c u r r e n t p r o c e s sAssessing you current level of performance is a two-step process. The first step is to review any process measures datathat is collected by your hospital. Is the performance at an acceptable, reliable level? What is the compliance withthe central line bundle? Can you guarantee to every patient who requires a central line that he/she will receive all thecomponents of the bundle? The data gives you an insight into how well your process is performing.

Front-line staff can provide a general understanding of how the steps of your current processes are currently beingcarried out. Even if your organization has not yet implemented a process such as dedicated equipment for infectedindividuals, it is a good idea to understand how processes are currently being done. To collect this information asimple way is to ask five front line staff what is the process. Or ask them to write out the process they follow.Compare the information collected from each staff. This will provide you a quick way to gather information, tell you ifthe process or procedure is being done as it is intended and direct you in refining or developing your processes.

R e l i a b i l i t yThe American health care system does not perform as well as it could. Recent studies show there is a gap in the carewe deliver and the care we should deliver for which solid research evidence exists, whether in acute, chronic, orpreventive situations. Studies by the RAND Corporation report that only about 50% of patients receive care consistentwith evidence-based recommendations1.

Reliability is the ability of a system to perform and maintain its functions in routine circumstances, as well as inunexpected circumstances. Reliability principles are methods of evaluating, calculating and improving the overallreliability of complex systems. These principles have been used effectively in industries such as manufacturing andaviation to improve both safety and the rate at which the system produces the desired outcomes. By applying reliabilityprinciples to healthcare, we can close the gap between the care we give and the care we should give based, on theevidence-based recommendations.


DefinitionsIHI defines reliability in health care as “the measurable ability of a health-related process, procedure, or service toperform its intended function in the required time under commonly occurring conditions.”2 Another way to say this is thatreliability equals the number of actions that achieve the intended result, divided by the total number of actions taken3.From the patient perspective, this is an all or none measure. That is, patients receive all of the elements of careassociated with a process in order to be considered reliable.

Reliability = Number of actions that achieve the intended resultTotal number of actions taken

Failure rate, or unreliability, calculated as 1 minus reliability is used as an index expressed as an order of magnitude.For example 10-2 means that one time in 100 the action fails to achieve the intended result. The following aredefinitions used by the IHI Reliability Innovation Team in applying reliability to health care processes4. (Please note thatthese aren't strict mathematical definitions.)

• Chaotic process: Failure in greater than 20% of opportunities. This means if you perform a process witha success rate of 75% or less, the process is considered “chaotic.”

• 10-1: One or two failures out of 10 opportunities or 80% or 90% success. For example, central linebundle compliance is at 80%.

• 10-2: Five or fewer failures out of 100 opportunities or a 95% success. (Although the mathematicaldefinition of 10-2 would be one failure out of 100 opportunities, remember the IHI Innovation Team hastaken liberties with the mathematical definition.)

• 10-3: One failure out of 1000 opportunities or 99% success.

The key to understanding a 10-1 level of performance is that no articulated process exists. If you asked five frontlineindividuals to describe the process, less than five will be able to do so. With a 10-2 level of performance, fivefrontline individuals can easily articulate the process but with some variation. A 10-3 level of performance on processmeasures indicates a well-designed system with attention to system design based on human factors engineering. In abroader context, aviation passenger safety and nuclear power plant safety is measured at 10-6. However, in healthcare patients receive the indicated care about 50% of the time or less than 10-1 reliability (chaotic level ofperformance.)

Designing a reliable system To be highly reliable, systems must be designed to compensate for human fallibility. Human factors engineeringstrategies assist in designing a reliable system. IHI uses a three-tier strategy to design reliable care systems: prevent;identify and mitigate; and redesign5.

Prevent: The idea with this first strategy is to prevent initial failure by using intent and standardization. This typicallyresults in 10-1 performance. The focus is on the use of a standardized approach to care for patients. Tools andtechniques used at this level of performance include standard order sheets, guidelines, checklists, feedback mechanismsand education/training.


Identify and mitigate: This tier focuses on catching and alleviating defects. Concepts used at this level seek toreduce opportunities for humans to make mistakes and are often referred to as “error-proofing.” Some common toolsand techniques are decision aids and reminders built into system, the desired action is the default, redundantprocesses, taking advantage of habits and patterns, visual and sensory clues and barriers.

Redesign: This tier is the 10-3 level of performance and beyond. The tier involves identifying weaknesses in thedesign of the standardized process that might lead to failure in the future. A Failure Modes and Effects Analysis(FMEA) is a tool used to redesign the process once a 10-2 level of performance is reached.

Using Segmentation in Reliable DesignWorking in segments is a key part of applying reliability science. A segment is a portion of the topic that can beclearly identified. Examples include patient populations, admission routes, and physician groups. Based on projectmanagement techniques, it is recommended that the segments of a population be identified first, with carefulidentification as to their differences and the different types of changes that each may require. This will allow forcustomization for the difference segments of the population.

Segmentation is helpful in using reliability to improve processes6:• Allows for the control of some variables• Defines the boundaries around which sequential expectations for success can be found• More likely to test the validity of the design rather than deal with barriers• Fosters a deeper understanding of the design complexity required for the project• Forces understanding of the differences between segments as design strategies• Allows the formation of predictable timetables.

Eventually you have to be able to apply the process to the entire population. Therefore, limit the segments of thepopulation to no more than four segments. In choosing your first segment the following requirements should beconsidered7:

• The segment needs to represent a significant volume• The segment should have clear and distinct boundaries• The segment should have willing participants (eliminates the barrier of agreeing)• The segment should allow for key articulated variables or barriers to be neutralized• The first segment should establish the design team

Use Tool 4C_ Segment Design Table to the segments in your population.

Steps to designing a reliable processIHI, through its work with hospitals working on reliability, created a template for increasing the reliability of healthcareprocesses. The framework is based on the prevent, identify-and-mitigate, redesign approach8,9. The following tableuses the template to outline the steps you can use to design or redesign a reliable process.


Table 4.2 Designing a Reliable Process


T h e M o d e l f o r I m p r o v e m e n tThe Model for Improvement was first published in 1992 by Langley, Nolan, et al, in “The Improvement Guide: APractical Approach to Enhancing Organizational Performance.”10 This model provides a framework for developing,testing and implementing changes in the way we do things. It is a simple approach that is highly effective and reducesthe risk associated with changing something we do by utilizing small tests of change. Highly successful organizationsfaithfully use the model for performance improvement. Reliability design methodology is intimately linked with rapid-cycle tests of change. If you use the Model for Improvement in this project you will be more successful in improvingyour care processes.

Improvement comes from the application of knowledge. The more knowledge you have the better the improvement willbe when you apply the knowledge. Therefore, your approach to improvement is based on building and applyingknowledge. The Model for Improvement is a tool to help you build knowledge and then apply it. The model consistsof two parts: the fundamental questions or the “thinking” part and PDSA cycle or the “doing” part.

Fundamental Questions for Achieving Improvement1. What are we trying to accomplish? The key idea to answer the first question is to develop an aim statement for the project. For example the aim of thenational SCIP collaborative is to “reduce the incidence of surgical complications by 25% by 2010.” An aimstatement has several important characteristics. A good aim statement is specific, measurable, timely, andidentifies a population to which the improvement is focused. For example: By Sept 30, 2008 central line bundlecompliance will be 95% in SICU patients. Use Tool 4A_Aim Worksheet to develop your aim.

2. How will we know that the change is an improvement?To understand if you are making an improvement it is necessary to collect data. Data includes chart audits andinformation obtained from those that was involved in the “doing” part or the PDSA. Data or measure needs to berelated to your aim statement. If you choose to work on improving hand hygiene compliance, then the data youcollect would not include the number of patients with active MRSA surveillance cultures. Chapter 5 of the tool kitexplains the data we are collecting for this project.

3. What changes can we make that will result in improvement?By brainstorming, the team will determine possible change concepts or ideas. One change idea to test will beidentified. The detailed plan for the test, including the day, time, the location and the people involved, will beplanned.

The PDSA CycleThe second part of the model for improvement, the “doing” part, consists of four components, plan, do, study, act, orPDSA. We refer to these cycles as test cycles.

Plan:The plan should include the objective, any predictions, the plan to carry out the cycle (who, what, where, when)and the plan for data collection. The detailed plan for the test of change should be shared with all involved in theprocess, and the plan will be executed.

Do:This is actually carrying out the plan, documenting the observations and recording the data. Obtaining feedbackfrom all involved in the test of change will determine the success of the new process (elimination of discrepancies),or if additional tests of change need to be explored.


Study: Analyze the data by comparing it to the predictions and summarize what was learned.

Act:You will want to re-run the test of change with a new or modified change idea if the evaluation of your first test ofchange reveals problems. Once you determine that your improved process is effective, the new process will needto be tested with an expanded population. For example, expand the test beyond Dr. Smith's patients to all thepatients admitted to the MICU.

Use Tool 4B_PDSA Worksheet for each test cycle. The worksheet forces the team to be explicit in terms of the individualresponsibilities in the design of the test, the tasks needed to be done before the test is carried out, and the measures tobe used to decide if the test was successful. Keep each worksheet in a notebook along with any data collected for thetest cycle. This will provide you with information for future reference and assist you when you are telling your story ofhow you reliably implemented the measures to eliminate MRSA infections.

R e f e r e n c e s :1. McGlynn EA et al. NEJM. 2003;348(26):2635-45.2. IHI Innovation Team paper, Designing Reliability in Health Care Processes. Jan 20073. Lloyd Provost. Designing Reliable Health Care Systems presented at the AIM workshop, Mar 2006.4. IHI White paper, Improving the Reliability of Health Care. 20045. Ibid. IHI White paper6. Resar RK and Stroebel RJ. Using Segmentation to Facilitate Reliable Design in Improvement Projects presented at

the IHI Annual Forum, Dec 2005.7. Resar RK and Federico F. How to Design Reliable Processes in Healthcare presented at IHI Designing Reliable

Delivery of Optimal Care, May 2007.8. IHI Innovation Team paper, Designing Reliability in Health Care Processes. Jan 20079. IHI White paper, Improving the Reliability of Health Care. 200410. Langley GJ et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.

1996.

5M e a s u r e m e n t


M e a s u r e m e n t 5U s a g e o f d a t a c o l l e c t i o n

Data is important in all aspects of our lives. We use data in our personal and professional lives. Data allows us tomeasure how well we are doing on a process, a requirement or an idea for new knowledge. In healthcare datacollection is used in many ways including quality improvement, regulatory requirements and research. However, eachof these types of data collection has different characteristics and aims.

In quality improvement data collection is focused on small-sample, real-time data collection. As a result we candetermine if changes are resulting in improvement. The aim is to collect small sequential samples of cases with near“real time” feedback. This will allow for the acceleration of learning, consultation and change modification necessaryfor rapid improvement in care process. Your data collection strategy should be robust enough to demonstrate ifimprovements have been obtained, yet simple enough to collect so it is not burdensome.

Below is a table that compares the facets of data collection for three different purposes.

Table 5.1


D e f i n i t i o n o f M e a s u r e s

The data collected for this collaborative includes the following components:1. Self-Assessment - An organizational assessment based on SHEA guidelines to determine the progress made by

the participating organizations in implementing a comprehensive organization-wide program to preventnosocomial transmission of MRSA. Change strategies and suggested measures are provided on the form.

2. Hand Hygiene Compliance Measures assessing hospital healthcare workers' compliance to hand hygieneprotocols as specified by SHEA guidelines

3. Barrier Precaution Compliance Measures assessing hospital healthcare workers' compliance to barrierprecaution protocols as specified by SHEA guidelines

4. MRSA Infection Rates based on populations identified through both clinical and surveillance culture.

Each data component has a simple data collection tool to assist you in collection and analysis of your data. Each toolincludes instructions on how to complete as well as definitions used in the tool. Required and optional data fields areidentified on the MSRA monthly data collection and the general hand hygiene tools. Copies of these tools are at theend of the chapter.

Once your data is collected you will enter summary level data, extracted from these tools, into an online application.The application is a robust tool providing real time feedback on your hospitals performance. Features of theapplication include providing a variety of tabular and graphical reports, comparative reports based customizedgroupings of hospitals, department/unit specific and aggregate trending reports and the capability to download dataand graphics for further analysis or use in presentations.

Collaborative Data Tools• Tool_5A Self Assessment Checklist• Tool_5B General Hand Hygiene• Tool_5C Barrier Precautions• Tool_5D MRSA Monthly Data Collection Tool


C o l l e c t i o n R e q u i r e m e n t s a n d S c h e d u l e

You will need to measure data before you start your performance improvement cycles (i.e., baseline data) and thencontinue measuring as you refine the process with additional tests of change. This will help you understand the impactof your changes and determine if additional changes are needed.

A self-assessment is performed at the beginning and the end of the collaborative. Every month you will use the MRSAmonthly data collection tool to submit data regarding number of patient days, number of admissions, MRSA infectionsand MRSA isolates from clinical and surveillance cultures. The information is entered no later than the 30th of thefollowing month for which it was collected.

Data regarding hand hygiene and barrier precautions is collected every six months. You will observe up to 30 randomobservations for each process. It is recommended that this is done in a time frame before the due dates listed in table5.3.

Table 5.2 Eliminating MRSA Online Data Reports


Table 5.3 Data Collection and Submission Timeline


Tool

_5A


Tool_5B

69N o r t h C a r o l i n a E l i m i n a t i n g M e t h i c i l l i n - R e s i s t a n t S t a p h y l o c o c c u s a u r e u sTo

ol_5

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Tool_5C

71N o r t h C a r o l i n a E l i m i n a t i n g M e t h i c i l l i n - R e s i s t a n t S t a p h y l o c o c c u s a u r e u sTo

ol_5

C

72 N o r t h C a r o l i n a C e n t e r f o r H o s p i t a l Q u a l i t y a n d P a t i e n t S a f e t yTo

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6S p r e a d i n g

a n d

F o r m a l i z e


S p r e a d a n d F o r m a l i z e6Spreading and formalizing your changes is an important part of implementation of new processes. It is necessary inorder to achieve an overall improvement in reduction in infections at your hospital. Spreading can be to otherpopulations in the same area or to other areas within your hospital. For example, you may have started in one ICUand will now move to another ICU or to a nursing floor. Spreading takes the process from the narrow segmentedpopulation(s) or group(s) and broadens it to include all the population(s) or group(s) that will use the process. Formalizing a process is necessary to provide a reference to those new to the organization; or clarity about thespecifics of the process to those in the organization.

S p r e a d i n g In the previous chapter, Performance Improvement, we discussed the importance of segmentation, taking a portion ofthe overall population, or a part of the process and using the Model for Improvement to develop or revise the process.After success is achieved with the segmented population, it is time to spread it to others. For example, you may havestarted with the MICU patients and you are now ready to spread this to the SICU patients. You may have started withthe elective admissions first, and now you are ready to spread to the non-elective or emergent patients. Spreadingyour process to other populations, other shifts, or other areas of the hospital will require a plan. The project teamshould decide the order in which to spread, who will be responsible for the spread, and the actual dates/times forimplementation. Spread should occur on similar patient populations, shifts or diagnoses first. As you introduce theprocess to the new population or area of the hospital, you will need to educate the staff and solicit feedback. Below isan example of a typical hospital spread plan.

As you spread you will need to take into account if variation exists between the units or populations. If there seems tobe substantial variation needed to the process, then it may warrant additional PDSA cycles be completed for that areaor population. Your goal is to account for the variation that may exist with slight modifications to the process.

Table 6.1 Example of a Spread Plan


As you introduce the process to the new population, area, or shift, you will need to educate the staff and solicitfeedback. At the end of this chapter, the Spread Process Checklist and Eliminating MRSA Process Inventory will assistyou with planning your spread.

F o r m a l i z i n g The final step to ensure that your process will be consistently and widely used is to write or revise your procedures andremove all evidence of old processes. This should be the last step that you do, only after you have revised your processusing the Model for Improvement and have spread it to the other populations and or areas. The team can be draftingthis as they revise the process, but it should not be finalized until the process has been spread. This will allow the teamto account for slight variations in the procedures for the different populations, shifts, and areas within the hospital. Yourprocesses should outline the new processes in your organization and the roles and responsibilities of staff. You willalso need to provide ongoing education of the processes for new members of the staff and hold existing staffaccountable for the new processes by incorporating this into yearly competency training and performance evaluations.Lastly, you will need to continue to monitor the effectiveness of the new processes. These steps will assist you informalizing your processes. At the end of this section there is an example of a Formalizing the Process Checklist

A c c o u n t a b i l i t yThere has been a paradigm shift in the way we used to do things in healthcare to the way that we are recommendingto do things today. This shift is highlighted in this Tool Kit. Traditionally, managers, directors and others inadministration sat in a room and wrote out the new procedure. There were often delays in getting the procedure intothe hands of the direct care providers as it went to several committees for approval. It was a top-down approach,where subordinates were expected to follow the procedure that was drafted by their superiors. There wasadministrative ownership of the procedure, creating a disgruntled and apathetic culture at the direct care provider level. In today's hospital environment we have moved to using the Model for Improvement, Chapter 4, to transform our careprocesses. The Model for Improvement takes an interactive approach, involving and engaging the direct careproviders. It is an agile approach, supporting rapid tests of change to develop or revise a procedure. The direct careproviders have ownership into the new or revised procedure. Hospital leadership supports the hospital teams and theirincorporation of evidence-based care processes. The Model for Improvement enables the team to tailor the processesto the needs of their hospitals (units). The end product is the development of a more highly effective procedure.

After developing or revising the procedure using the Model for Improvement, spreading it throughout the organizationand formalizing it by drafting a written procedure, there is an expectation that the direct care providers will abide by it.What if this is not the case?

Consider the following scenario: a new hand washing procedure developed by the project teams using the Model forImprovement that addressed all the system issues that the staff could identify for not washing hands. Soap, sinks, papertowel and alcohol foam dispensers were readily available for the staff. The staff had been educated on the risk of

Communicate Project to OthersSpreading • Meet with leadership and medical executive committee • Meet with departments affected the most• Send newsletters, post postersFormalizing • Post permanent reminders of the new process• Communicate success of the new process


spreading infections and the harm that this can inflict on their patients. A month after the new process was in place, itwas observed that the hand washing process had achieved a level of reliability of 10-2 (five or fewer failures out of100 opportunities) or 95% compliance. There appeared to be one or two nurses that routinely did not followprocedure. When confronted, the nurses stated “ I do not have time to wash my hands in between patients.”

How do you hold the provider accountable, yet support a culture of safety? A model that can assist with accountabilityis the Just Culture Model developed by David Marx, JD, Outcome Engineering, LLC. The term “Just Culture” refers to asafety-supportive system of shared accountability where healthcare institutions are accountable for the systems they havedesigned and for supporting the safe choices of patients, visitors and staff. Staff in turn are accountable for the qualityof their choices - knowing that we cannot will ourselves to be perfect, but we can strive to make the best possiblechoices.”1

The Just Culture model categorizes behavior into three categories, human error, at-risk-behavior (unintentional risk taking)and reckless behavior (intentional risk taking). In the scenario above, if the nurse had several tasks that she needed toaccomplish and when she entered the patient's room and she forgot to wash her hands. This is an example of ahuman error, an omission. In a Just Culture we would console the nurse and develop systems (reminders, patienteducation, alcohol foam dispensers in a more prominent place) that would make it difficult for the nurse to forget. At-risk-behaviors are where providers violate procedures thinking they are in a safe place. If the nurse consciouslyelected to not wash her hands because she was busy with other tasks and didn't think there were any immediateconsequences (harm) to the patient, this would be an example of an at-risk-behavior. In a Just Culture we wouldcoach/counsel the nurse for at-risk-behaviors. If they are repetitive at-risk-behaviors, and the source of the error doesnot reside in the system, then we would discipline the nurse.

Reckless behaviors are where the provider intentionally, or purposefully causes harm. In the scenario above, if thenurse cared for a known infected patient and then cared for another patient without washing her hands to infect thesecond patient, this would be an example of reckless behavior. In a Just Culture we would discipline the nurse forreckless behavior.

As we look at compliance and accountability with newly developed or revised processes it is important to assure thatthe process has reached a level of reliability. Once it is established that the process is reliable, the Just Culture modelcan be used to achieve a level of accountability.

Outcome Engineering, LLC has developed an algorithm to assist managers in categorizing behaviors and providingconsistent responses to the behavior. Information about Just Culture and its tools can be found online atwww.justculture.org.

R e f e r e n c e s :1. Patient Safety and the Just Culture, Overview, Outcome Engineering, LLC. Curators of the Just Culture Community,

Copyright 2006. www.justculture.org.

7R e f e r e n c e

M a t e r i a l s


R e f e r e n c e M a t e r i a l s7D a t a M a n a g e m e n tHand Hygiene Data/Audit Collection ToolsTool_7A Providence AK Medical Center HH Audit ToolTool_7B Alegent Health HH Audit ToolTool_7C NC Baptist Hosp HH Audit ToolTool_7D UNC Contact Precautions Audit Tool Environmental Service Data/Audit Collection ToolsTool_7E Alegent Health EVS Audit Tool

P r o v i d e r To o l s Tool_7F Providence AK Medical Center Physician Inf Control Note Tool_7G NC Guide for Mana of CA-MRSA StaffEdTool_7H Reid Hosp Nasal Spec StaffEd (VHA Share & Learn)Tool_7I HH Spies-Brief Inf Con StaffEd (VHA Share & Learn)Tool_7J Eastern ME Med Surv Script StaffEd (VHA Share & Learn)Tool_7K Sharon Reg Med System pp StaffEd (VHA Share & Learn)

P a t i e n t E d u c a t i o n To o l s Tool_7L CDC PtEd (http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html)Tool_7M Providence AK Medical Center PtEdTool_7N WA Dept Health PtEd (http://www.doh.wa.gov/Topics/Antibiotics/MRSA.htm)Tool_7O Billings Clinic PtEd (VHA Share & Learn)Tool_7P Stamford Health Sys PtEd (VHA Share & Learn)Tool_7Q Martin Memorial Pt.Letter PtEd (VHA Share & Learn)

L i n k s Tool_7R Links

G l o s s a r yTool_7S

L i t e r a t u r eTool_7T Literature- References


Tool_7N WA State Dept. Health PtEd

PO Box 4449, Cary, NC 27519-4449Tel 919-677-2400 www.ncha.org/ncchqps

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