3 Who is responsible for preventing HAIs? Is there will to change?Who needs to be accountable and for what?Is the system capable?How to get physicians engaged.A helpful model
4 Will – Ideas – Execution Achieving results at the system or organizational level requires WILL at all levels, but especially the will of the top management.The new system will require new IDEAS about how work gets done, how relationships are built and how patients participate in their care.EXECUTION is a framework of strategic initiatives armed at producing system level results.
5 The way to success… Establish the WILL for change Identify superior, evidence-based IDEASDevelop an EXECUTION strategyThe Model for ImprovementWhat are we trying to accomplish?How will we know a change is an improvement?3. What changes can we make that will result in improvement?
6 Building Will In God we trust…all others bring data Incentives Culture of SafetyPride and duty
7 Driver DiagramThis is a type of tree diagram, a tool to conceptualize an issue and its system components.This diagram also helps to demonstrate a pathway to achieve the desired outcome.
8 What changes can we make? Understanding the SystemProcess ChangesSecondary DriversPrimary DriversOutcomeChange 1P. DriverS. Driver 1Aim: An Improved SystemS. Driver 2Change 2S. Driver 3P. DriverChange 3S. Driver 1S. Driver 2DrivesEffectCause
9 What changes can we make? Understanding the System for Reducing Hospital Acquired InfectionsSecondary DriversPrimary DriversOutcomeS1. Identify patients with ASCS2. Use contact precautions for colonized or infection patientsP1. Prevention of transmissionSee the ‘Change Package’S3. Use appropriate room cleaning and disinfectionO1. Reduce infections from MRSA, VRE and C. difficile by 30%S4. Use dedicated equipment for colonized and infected patientsS5. Reliable hand hygieneP2. Prevention of infectionS6. Comply with all central line bundle componentsS7. Comply with all Ventilator bundle componentsS8. Use decolonization to decrease burden of organisms
10 What changes can we make? Understanding the System for Reducing Hospital Acquired InfectionsSecondary DriversPrimary DriversPercent of appropriate patients with admission surveillance culture collectedOutcomeS1. Identify patients with ASCS2. Use contact precautions for colonized or infection patientsPercent of patient encounters with compliance for contact precautionsP1. Prevention of transmissionS3. Use appropriate room cleaning and disinfectionPercent of environmental cleanings completed appropriatelyO1. Reduce infections from MRSA, VRE and C. difficile by 30%S4. Use dedicated equipment for colonized and infected patientsPercent of successful opportunities for appropriate hand hygieneS5. Reliable hand hygieneP2. Prevention of infectionS6. Comply with all central line bundle componentsCompliance with central line bundleS7. Comply with all Ventilator bundle componentsCompliance with ventilator bundleS8. Use decolonization to decrease burden of organisms
12 HAI Change Package S5. Reliable hand hygiene Secondary DriverIdeas for PDSA TestingSuggested “mini-measures” for PDSA testingS5. Reliable hand hygiene0. Pre-change activities: Build knowledge about infection, transmission principles, hand hygiene, and hand washing techniquePercent of a random sample of 10 front-line staff who can describe transmission principles and techniques0. Pre-change activities: Design processes and create infrastructure to support reliable hand hygienePercent of a random sample of 10 front-line staff who can describe procedures for reporting needed supplies1. Create a culture that supports reliable hand hygiene. Suggested change:Opinion leaders and staff report discussion and modeling2. Use reminders at the point of care. Suggested changes:Measure #5: Percent of patient encounters with appropriate hand hygiene3. Monitor and provide feedback about performance. Suggested changes:Percent of a random sample of 10 staff who are aware of hand washing complianceS1. Identify patients with ASC1. Identify patients who will be cultured. Possible alternative strategies include:Percent of patients appropriately identified2. Design and test a reliable process to obtain cultures and transmit them to the lab. Possible changes include:Percent of applicable admission for whom culture was received at lab3. Design and test reliable and timely processes for processing the cultures and notification of results. Planning activities and changes include:Percent of culture processed within 24 hours4. Take appropriate action when tests are positivePercentage of patients for whom tested positive
14 Engaging Physicians in Quality and Safety 1.1 Improve patient outcomes1.2 Reduce hassles and wasted time1.3 Understand the organization’s culture1.4 Understand the legal opportunities and barriers1. Discover Common Purpose:6. Adopt an Engaging Style:6.1 Involve doctors from the beginning6.2 Work with the real leaders6.3 Work with early adopters6.4 Make physician involvement visible6.5 Build trust within each quality initiative6.6 Communicate candidly6.7 Value physicians time with your time2. Reframe Values and Beliefs:2.1 Make physicians partners, not customers2.2 Promote both system and individual responsibility for qualityEngaging Physicians in Quality and Safety3. Segment the Engagement Plan:5. Show Courage:5.1 Provide backup all the way to the Board3.1 Use the 20/80 Rule3.2 Identify and activate champions3.3 Educate and inform structural leaders3.4 Develop project management skills3.5 Identify and work with “laggards”4. Use “Engaging” Improvement Methods:4.1 Standardize what’s standardizable, and no more4.2 Generate light, not heat, with data4.3 Make the right thing easy to try4.4 Make the right thing easy to do
15 Engaging Physicians in a Shared Quality Agenda ReferenceReinertsen JL, Gosfield AG, Rupp W, Whittington JW.Engaging Physicians in a Shared Quality AgendaIHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; (Available on
16 Winning Execution Strategies Pick a patient segment upon which to testWork with those who want to work with youSmall tests of change, small tests of change, small tests of changeLearn as you go: develop process for review and improvementEncourage customization
17 What Does the Evidence Tell Us? Rational Interventions Should Target Modes of MRSA TransmissionPerson-person via hands of health care providers – by far the most importantPersonal equipment (e.g., stethoscopes, PDAs and clothing)Environment contaminationAirborne transmissionCarriers on hospital staffRare common-source outbreaks
18 Prevention Infection and Colonization Colonized patients comprise the reservoir for transmission (“colonization pressure”)High rates of MRSA colonization complicate empiric antibiotic therapy (e.g., vancomycin)Colonized patients have a high rate of MRSA infection-Nearly 1/3 develop infection, often after dischargeColonization is long-lasting, and patients can transmit MRSA to patients in other health care settings (e.g., nursing homes), as well as to family members
19 Five Key Interventions Hand hygieneDecontamination of the environment and equipmentActive surveillance cultures (ASCs)Contact precautions for infected and colonized patientsCompliance with Central Venous Catheter and Ventilator Bundles
20 Causes of Failure in Making Transformational Change Not establishing a sense of urgencyNot forming a powerful enough guiding coalitionLacking a visionUnder communicating the vision by a factor of tenNot removing obstacles to the new visionNot systematically planning for and creating short term winsDeclaring victory too soonNot anchoring the changes in the corporation’s cultureJohn P. Kotter, Harvard Business Review
21 What It Takes to Improve a System “Change is possible if we have the desire and commitment to make it happen.”-Mohandas GandhiWillCQIIdeasExecution“Just do it.”-Nike“Every system is perfectly designed to achieve the results that it gets.”- Paul Batalden