This section of the report addresses the question, "How did the project work?" In other words, how was the project implemented? Overviews of the national project management structure and implementation processes are described, along with a brief summary of the education, coaching, and performance monitoring components of On the CUSP: Stop BSI.
The On the CUSP: Stop BSI project was a large quality improvement collaborative with many stakeholders and a complex implementation. Having an evidence-based change package was necessary but not sufficient to managing this large, multifaceted national project. Building and maintaining a solid implementation and project management structure crucially contributed to the project's success. The following briefly describes the roles and responsibilities of the National Project Team—HRET, Armstrong Institute, and MHA Keystone—which oversaw all aspects of project implementation.
National Project Team
The National Project Team (NPT) united three organizations with distinctive expertise and experience to contribute to the overall national effort—HRET, the Armstrong Institute, and MHA Keystone. The lead responsibilities of each partner are listed in the chart below.
|HRET||HRET was the prime contractor of the project and was responsible for project administration and management, budget oversight, recruitment of States, and development of State lead resources.|
|Armstrong Institute||The Armstrong Institute provided educational content and resources for implementation at the hospital unit level. They conceived and developed CUSP and provided faculty who coached hospital teams and presented at educational meetings.|
|MHA Keystone||MHA Keystone coordinated data collection and reporting and provided project implementation and coaching support. They provided faculty who coached hospital teams and presented at educational meetings.|
Understanding the needs and potential contributions of all of the different stakeholders was also important at the national and State/regional levels. The following table describes the major stakeholder groups and their role in this project.
|Department of Health and Human Services (HHS)||HHS is the United States Federal Government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.|
|Agency for Healthcare Research and Quality (AHRQ)||One of the 11 agencies within HHS, AHRQ supports research that helps people make more informed decisions and improves the quality of health care services. AHRQ funded the On the CUSP: Stop BSI project.|
|Technical Expert Panel (TEP)||The TEP was composed of clinicians, researchers, policymakers, and State hospital associations. TEP members provided input to the NPT on program implementation and evaluation.|
|Hospital Associations||State and regional hospital associations were responsible for the recruitment of hospital units, leading monthly coaching calls, convening statewide face-to-face educational meetings, and coordinating the project at the State or regional level.|
|Hospital Units||Hospital units were recruited by the State/regional hospital associations. Hospital units were responsible for collecting and submitting project data, implementing CUSP in their unit, participating in coaching and content calls, and attending face-to-face educational meetings with other units in their State/region.|
|Patients and Families||Patients and families were the ultimate target audience for this improvement collaborative.|
To manage the range of activities and multiple deliverables associated with this large and complex project, HRET built an internal operations team and developed standardized processes to implement the program and monitor and report progress. HRET designed its project management structure based on six key functional areas: 1) State lead program management resources, 2) recruitment and State hospital association relationship management, 3) administration and analytic database management, 4) communications, and 5) contracts and financial management. Individual staff members were identified and responsible for overseeing each of the functional areas.
Teleconferences and In-person Meetings
State leads and their participating hospital units were expected to attend or listen to archived recordings of five weeks of immersion calls as well as monthly didactic content calls, which began one month after the end of the immersion calls. Monthly supplemental calls were optional and provided information that was related, but not core, to the CUSP model or CLABSI elimination strategies and techniques. All calls were archived on the project Web site, http://www.onthecuspstophai.org . Unit teams began presenting on monthly supplemental calls after several months into the project and once State leads were able to identify excelling teams. State leads and the NPT received positive feedback from unit teams on this peer-to-peer teaching.
State leads were required to host at least two in-person meetings throughout the course of their two-year participation, and most States hosted three meetings. The kick-off meeting occurred approximately 1-3 months after the immersion calls, the mid-course meeting was approximately 12 months later, with the final meeting occurring any time between 24 and 28 months after the State/region's start of the program. States with low numbers of participating hospitals spread geographically far apart such as Idaho, Montana, Wyoming, and North Dakota held combined webinars for some of their meetings. In almost all cases, these meetings were attended by at least one Armstrong Institute faculty member and an HRET staff member. An MHA Keystone advisor typically only attended the kick-off meeting to help teams acclimate to the web-based data repository, Care Counts, maintained by MHA Keystone.
Manuals and National Program Web Site
The On the CUSP: Stop BSI change package had two major components—an adaptive portion and a technical portion. The adaptive work was to create a culture of safety using CUSP to improve teamwork and communication and to investigate and correct defects. The technical work was to reduce CLABSI through an evidence-based practice bundle or change package. Both objectives and the key steps to achieving them are listed in Figure 1 below. In addition to the immersion calls, monthly content and supplemental calls, and in-person meetings, all State leads and hospital units were instructed at the start of the program to review the CUSP Manual to improve safety culture and the CLABSI Implementation Guide to eliminate CLABSI, available on the national program Web site, http://www.onthecuspstophai.org . The CUSP Manual has been expanded and is now called the CUSP Toolkit. AHRQ publicly released the CUSP Toolkit in September 2012.
Figure 1. Project Objectives
Each State/region was assigned two advisors—one from the Armstrong Institute and one from MHA Keystone—to coach teams on monthly calls and to be available to answer State lead and unit team questions between calls. Armstrong Institute advisors used the time on coaching calls to reinforce content from the most recent content call, whereas the MHA Keystone advisor helped teams focus on their teamwork and CLABSI rate data and share the Michigan experience.
These coaching calls were led by the State lead and always included a monthly review of CLABSI and teamwork data. The advisors would often dedicate time to a particular CUSP tool. Each call had ample time on the agenda to allow teams to ask questions about interventions and data collection and to share their experiences.
Given the limited number of faculty advisors and the need to encourage State leads to learn how to coach on their own, the NPT developed a schedule in which State leads coached teams on their own after a year's experience with NPT coaches. Some States combined their coaching calls with those of other States in order for State leads to support each other in the coaching process.