1. 1 Reducing Healthcare Associated Infections (HAI): Barriers and Challenges MHA Keystone Center for Patient Safety and Quality (MHA Keystone) Chris George, RN MS MHA Keystone Center for Patient Safety and Quality AHRQ HAI Meeting September 27, 2010

2. Core Project Team HRETMHA Keystone Deborah Bohr, PISam Watson, Co-PI Kevin Van Dyke Christine George, RN John Combes, MD Morgan Martin Kimberly Sepulvado, RN

3. Study Objectives Evidence-based Practice: How did clinicians and hospital staff learn about evidence-based practice to prevent and mitigate HAI’s? Adaptive Work and the Comprehensive Unit- based Safety Program: How did teams get started with the adaptive work and what barriers were encountered? Critical Success Factors: What were the critical success factors in getting started? Future Research Needs: What types of AHRQ research are recommended? 3

4. Study Methods HAI Information Collection and Reporting Summary: completed by the infection prevention lead at each hospital Patient Safety and Infection Prevention Catalogue: completed by the patient safety/quality improvement officers of each hospital Patient Safety and Infection Prevention Assessment: clinicians and other staff Semi-structured interviews with ICU coordinators at each facility 4

5. Assessment Findings DomainMean Hospital Score (highest=5) A N=20 CLABSI B N=54 CAUTI C N=24 VAP D N=48 Sepsis General Work Environment4.53.94.14.3 Attitudes4.44.2 4.3 Practices3.8 3.94.0 Mean % Yes Answers to Questions Awareness of Patient Safety Training and Guidelines 75-9586-949692-98 Compliance with Patient Safety Practices 95909490 5

6. 6 Context: The Michigan Experience  History  Results  “Perfect is Possible”  AHRQ and JHU collaboration

7. Comprehensive Unit-Based Safety Program (CUSP)  AHRQ-funded JHU-MHA Keystone success  CUSP elements:  Educate staff on the Science of Safety  Identify defects in care  Commit executive leadership to patient safety at the unit level

8. 8 Participating MHA Keystone Hospitals FacilityType# Beds HAI Prevention Effort Timeline # IC FTEs A Small/rural, non-tertiary, community, non-profit 73BSIEarly 20051.5 B Tertiary, community, non-profit 243CAUTI20031.5 C Tertiary, community, non-profit 411VAPLate 20032 D Tertiary, teaching, community, non-profit 529SepsisEarly 20044

9. 9 What Each Hospital Has in Common  Experience in the Keystone ICU Collaborative since 2004  Evidence-based practice specific to the HAI  Comprehensive Unit-Based Safety Program

10. 10 Barriers and Challenges  Resistance from front-line staff  Naïveté about resource requirements  Unrealistic data collection plans  Lack of staff support for multidisciplinary rounds  Time needed for practice change to take hold

11. 11 Key Lessons  Provide staff with strong evidence base  Communicate expectations and require accountability  Provide strong administrative support  Do what works locally  Use multiple venues to raise awareness and reinforce practice  Observe staff on rounds and provide regular real-time feedback

12. 12 Key Lessons (Cont…)  Provide performance data at least quarterly and post in unit  Establish Nurse Protocols  CUSP critical to success  Start small, then expand  Use arsenal of QI tools; change management, systems, small cycle change, in addition to CUSP tools  MD and RN champions essential

13. 13 Next Steps  Major need for implementation research  Best practices for implementing latest evidence- based practice  Dedicated time for clinicians  Create this mindset in medical and nursing students—start education early!