1. Community Health Network and The Indiana Heart Hospital’s Collaborative with Regenstrief Institute to Reduce MRSA Infections

2. Indy ACTION Project-Reducing MRSA Partnering with six local health systems (Clarian, Community, St. Francis, St. Vincent, VA, and Wishard) Training for staff on LEAN and process reengineering techniques to adapt implementation. Bundle consisting of culturing on admission, barrier isolation, and hand-hygiene using front- line staff. Informatics tool to deliver up-to-date MRSA data between hospital groups.

3. Key Elements for Success Staff engagement in culture change Data Collection Real time data feedback of admission and discharge swabbing rates and HA-Transmission & Infection rates. Weekly unit briefings involving administration, infection control, and staff. Leadership involvement and support.

4. Key Components MRSA Bundle Contact Isolation- all MRSA + patients HH, Gown, Glove Designated or Disinfected Equipment Cultural Transformation from Within Staff – own and operate solutions Leaders – Set direction, create freedom and opportunities for staff to co-create and implement solutions, remove barriers.

5. Key Functions of Regenstrief Core Group Meet Weekly Base camp – Web Site Sharing tools, Literature, Best practices Data Feedback Progress Updates

6. Intervention, Training, & Assessment Hand-Hygiene Protocol -Develop Hand-Hygiene Protocol/Training Perform Baseline Assessment -Baseline Knowledge, Barriers, Culture, Reported Adherence/Performance/Measurement Conduct Training -Conduct Training and Engagement of Frontline Staff Reporting Mechanism -Develop Feedback Mechanism and/or reporting mechanism for performance measures. -Deliverables 1. Development of periodic reporting mechanism to include a scorecard with compliance, colonization, and infection rates.

7. Accomplishments Facilitated acquisition of rapid PCR test for MRSA, available in lab ready for go live date. Facilitated change over to new culture swabs that will reduce confusion with swab selection. Educational brochure created for family/visitors regarding MRSA. Informational letter created to give to patients on admission explaining purpose of MRSA cultures. New signage at room entry added to assist hand hygiene compliance.

8. Accomplishments Standardized process for obtaining isolation carts. Alcare foam mounted on isolation carts. Hand lotion selected and placed on unit for staff. Developed process to have stocked isolation cart in (par-level) ready for use. Standardized supply list for isolation carts.

9. Accomplishments Isolation carts labeled to standardize location of supplies in cart drawers. Isolation supplies grouped together in Par level for easy access. Success in getting laundry to mark reusable gowns with # of times washed.

10. Successes Collaboration with other Indy hospitals and Regenstrief. Sharing of best practices. Expert training for staff on LEAN and process reengineering techniques. Assistance with data collection. Informatics tool to deliver data between hospitals. Communication of the results via public lectures and print.

11. Challenges IRB approval. Data collection tool ready to go the day initiative starts. Practice change for bedside staff. Sufficient research staff resources to spread study to other facilities and still support initial study groups. Clear endpoint for study.

12. Lessons Learned Front line staff as well as leadership have to own the process improvement for success. Staff require resources, education, and data feedback to successfully complete process improvement.

13. Continued Support To Improve Health Care Innovative ideas Sharing Best Practice Support and Communication