Final Report: Executive Summary (continued)
Results from our case studies are summarized below. First, to set the context for our results, we provide a brief descriptive summary of the case study sites' CLABSI prevention efforts. Second, consistent with our stated research questions, we present findings from our exploration of the role of HPWPs in reducing or preventing CLABSIs. Finally, we present findings from our comparison of CLABSI prevention efforts among hospitals that had better versus less satisfactory CLABSI outcomes.
We found that all of the sites' CLABSI prevention efforts focused on three main areas: clinical improvements, process improvements, and organizational improvements. While the organizations' approaches and specific foci varied, we found great similarity across sites. This finding is not surprising, given that the sites were selected based on participation in the CUSP initiative, and this was emphasized in many of the activities that we observed. The CLABSI prevention activities that we observed in each of these three main areas are summarized in Table 3.
Role of HPWPs in HAI Reduction
This study is an extension of a previous task order in which the research team explored the link between HPWPs and quality-of-care outcomes in health care organizations. In this followup case study research, we used an HPWP framework to explore the role of management practices in reducing CLABSIs. (Go to Appendix 1 for detailed definitions; also refer to Garman, et al., 2011.) Consistent with our overarching research questions, our exploration focused on (1) whether HPWPs facilitate consistent application of practices known to reduce or prevent HAIs and (2) whether implementation of these practices could be linked to HAI outcomes. These findings are based on comparisons of activities at five higher performing sites and three lower performing sites and are summarized below by HPWP subsystem.
- Subsystem #1: Engaging Staff. Practices for engaging staff increase employees' awareness of and commitment to achieving organizational goals. We found evidence of these practices as a critical component of CLABSI reduction efforts at all of the sites in our study. We observed differences between the higher performing sites and the three lower performing sites in the content, scope, and impact of these engagement practices.
- Subsystem #2: Acquiring and Developing Talent. Practices for acquiring and developing talent focus on improving the quality of the workforce through recruitment, selection, and/or employee development. All of the sites within this study emphasized training and employee development in their CLABSI prevention efforts. Overall, we found that the sites with higher performing CLABSI outcomes not only focused on training to support implementation of clinical changes, such as introduction of new products and processes, but also emphasized the development of new knowledge and skills designed to support broader safety goals, such as a "culture of safety."
- Subsystem #3: Empowering the Frontline. Practices for empowering the frontline include efforts to reduce status distinctions, ensure employees' security in their positions (e.g., foster freedom to speak up), and decentralize decisionmaking to emphasize input from frontline caregivers. These practices are an important component of the CUSP initiative, which emphasizes the importance of establishing a culture of safety and enhancing team communication and collaboration. While we observed some evidence of frontline empowerment at all of the sites, the focus and degree of success varied considerably.
- Subsystem #4: Aligning Leaders. Practices for aligning leaders—such as leader development, succession planning, and performance-linked compensation—are designed to enhance leader capabilities and support achievement of organizational goals. The most visible alignment practice was the incorporation of CLABSI rates and rate reductions as performance goals at the unit level (done at all hospitals) and as contributors to an organizational-level goal in four of the hospitals we studied (two higher performing, one lower performing, one control). However, in none of these hospitals were incentive payments directly tied to the accomplishment of CLABSI-related goals.
Key Differences Among Sites With Varied CLABSI Outcomes
We identified several key "success factors" for HAI prevention and reduction. These factors are listed below. The key success factors were widely evident in the sites identified as higher performing based on CLABSI outcomes, and either missing or inconsistently implemented in the lower performing sites.
- Belief that "zero" is attainable.
- Frontline accountability.
- Strong leadership at all levels.
- Infrastructure and resources to support improvement.
- Supportive organizational culture.
- Use of data.
Challenges to HAI Prevention and Reduction Efforts
We also identified several common challenges to HAI prevention and reduction efforts, outlined below:
- Resource constraints.
- Competing priorities.
- Tracking/monitoring problems.
- Changes in personnel.
- Open ICU model.ii
ii. Open ICU model—An ICU in which patients are admitted under the care of an internist, family physician, surgeon, or other primary attending of record, with intensivists available providing expertise via elective consultation. Intensivists may play a de facto primary role in the management of some patients, but only within the discretion of the attending of record.