Final Report: Executive Summary (continued)
Successful implementation of evidence-based interventions can lead to dramatic and sustained reductions of CLABSIs in hospital ICUs. These evidence-based interventions have been widely disseminated in the clinical literature (e.g., Berenholtz, et al., 2004). Further, collaborative quality improvement initiatives have successfully supported widespread adoption of these evidence-based interventions in multiple hospitals (e.g., Pronovost et al., 2006), resulting in fewer CLABSIs for participating organizations. Our findings provide insight about both the management practices and factors associated with more successful implementation of these CLABSI reduction interventions and highlight challenges associated with CLABSI prevention efforts.
Our analyses suggest that HPWPs do, in fact, facilitate adoption and consistent application of practices known to prevent HAIs. We observed a wide range of employee engagement practices (e.g., communication of CLABSI goals, keeping staff informed of progress in preventing CLABSIs, involving staff in decisionmaking) that were important in motivating staff to accomplish CLABSI reduction goals. Combined, these practices emphasized the importance of, and the organizations' commitment to, reducing CLABSIs. These efforts were supported by robust practices for acquiring and developing talent that were designed to make employees more knowledgeable about CLABSIs, to foster successful prevention, and to build employees' skills with an aim toward preventing CLABSIs. At the better sites, these development efforts were broader, seeking to enhance skills and commitment to safety among the wider workforce.
The success factors emphasized by the higher performing sites included (1) a belief that a rate of zero CLABSIs was attainable, (2) accountability for results, (3) strong leadership at all levels, (4) infrastructure and resources to support improvement efforts, (5) a supportive organizational culture, and (6) effective use of data. In contrast, several factors created challenges to CLABSI reduction efforts: (1) resource constraints, (2) competing priorities, (3) difficulties tracking/monitoring CLABSI data, (4) changes in personnel, and (5) an open ICU model. While it is difficult to eliminate other explanations for why success factors were more likely found among higher performing sites and barriers were more likely found among lower performing sites, these findings suggest that emphasizing CLABSI reduction goals and HAI prevention overall can help focus organizational improvement efforts and support initiatives designed to promote patient safety.
Our findings are consistent with those from a study of five collaborative regional HAI programs, which identified the following success factors: communication, frontline engagement, leadership support, and feedback and rewards (Welsh, et al., 2012). Further, in a study that demonstrated the sustainability of the Michigan Keystone Project, Pronovost and colleagues (2010) suggested that feedback about infection data, an “unremitting belief in the preventability of BSI [bloodstream infection],”' and leadership involvement were critical to long-term success. Our research confirms these findings and provides additional evidence to support the importance of management practices in HAI prevention efforts.
An important limitation of this study is associated with our study design. Both our case study design and our purposive selection of sites to study created limitations with respect to generalization of our findings. In addition, without comparisons among a greater number of organizations with a diverse range of management practices linked to CLABSI prevention rates, it is difficult to conclude with certainty that specific HPWPs or HPWP subsystems are critical to outcomes. Although participants at all nine sites were able to provide illustrations of connections between management practices and CLABSI prevention interventions and outcomes, these links were not rigorously tested.
Future research can move beyond the limitations of this study by using larger and more diverse samples that would permit contrasts of management practices and allow for quantitative analyses of associations between HPWPs and CLABSI and other HAI outcomes. There is also an important future opportunity to reexamine these hospitals' management practices and CLABSI prevention efforts in order to improve our understanding about what may promote sustainability and success with respect to improved HAI outcomes over time.
Additional information about this project can be found in both the peer-reviewed and trade literature. Citations are provided in the Bibliography.