Early in 2009, Julie Bryan, RN, CIC, Infection Prevention Coordinator, and Rob Carroll, MBA, Director of Performance Measurement and Improvement, presented a new way of thinking about HAIs to the senior leadership team of Shore Health System. Bryan and Carroll knew of other institutions that had brought their infection rates to zero in a short time period, rather than improving incrementally. They proposed a similar approach. They were surprised nevertheless when their Chief Eexecutive Officer (CEO) chartered them to “make zero happen” at Shore Health and his team agreed with him. Returning to Carroll's office afterward, he and Bryan looked at each other: Can we really do this? And if so, how?
Target Zero: Senior Leadership, Planning, and Launch
They began by setting up a multidisciplinary steering committee whose members included the Chief Medical Officer, Chief Nursing Officer, Chief Operating Officer, Director of Organizational Development, and Vice President of Communications and setting up a system-wide patient safety initiative named Target Zero. It aimed to wipe out three major device-related HAIs—CLABSI, CAUTI, and VAP—and take on hand hygiene across the entire Shore Health system. A regional, not-for-profit network of inpatient and outpatient services serving four rural counties on the Eastern Shore of Maryland, Shore Health is composed of two hospitals that merged in 1996, a cancer center, a home healthcare and hospice agency, a multispeciality physician group, and diagnostic and ambulatory centers.
The Target Zero Steering Committee began with the CUSP principle of engaging senior leadership. Bryan said, “some people's view had been, ‘infections happen, they're inevitable.' We had to show them research about what other hospitals had been able to do.” The immediate result, Carroll said, was that “senior leadership got fully on board, supported us, and gave us enough time to plan properly.” Leadership became so engaged that they aligned their goals and objectives with eliminating HAIs, provided a budget, held managers and directors accountable, participated in safety rounds and hand hygiene rounds, participated on the various committees involving Target Zero, empowered staff to do the right thing, reviewed monthly data and progress reports, and attended celebrations for units achieving zero HAIs for at least a year.
Over the next several months, Bryan, Carroll, and the Medical Director for Quality identified best practices for infection prevention from the literature. They also, Bryan said, “found out a lot about CUSP online at the Michigan Keystone ICU Project website to draw on for Target Zero.” The steering committee suggested doing a SWOT (strengths, weaknesses, opportunities, threats) analysis, which was carried out through 50 interviews with people throughout the system to get a baseline on how they thought about infections, and listen for opportunities to improve and to achieve zero. Committee members discussed best ways to get employee buy-in. They also talked with award-winning hospitals, borrowing materials from one that had had enormous success with hand hygiene.
On September 24, 2009, the Steering Committee formally launched Target Zero, which was attended by the entire senior leadership team. They discussed the initiative and their expectations at a meeting of 100 directors and managers. The CEO charged them with getting to zero HAIs, and aligning their resources with this goal. He gave them three principles: Imagine zero is possible, make zero part of the culture, and have fun doing it. Senior executives from marketing, human resources, and operations each told a personal story about how HAIs affect their areas of responsibility. The chief financial officer told of nearly dying from an HAI during a stay at another hospital. Bryan recalled, “it was a poignant moment. You could have heard a pin drop.”
Christopher Parker, RN, MSN, Chief Nursing Officer, and Senior Vice President for Patient Services then swooped in dressed as a giant, six-foot bug embodying all HAIs. Wherever he loomed, shrieks and laughter rippled. The Bug gave everyone a goodie bag containing a Zero candy bar, a bottle of hand sanitizer, and a card answering the question, “What is Target Zero?” The Bug then made the rounds at both hospitals for several hours well into the afternoon. Now dressed as the Bug, Bryan took the show on the road to all of Shore's facilities in a four-county area. Altogether, Parker, Bryan, and their helpers handed out over 2,500 bags while talking about Target Zero, and why they wanted everyone involved. Parker recalled,
“Going on the road was important. We went to all of our offsite locations. We got the word out that our high-powered steering committee was really committed and wanted to make Target Zero inclusive. Our tagline, ‘It begins with me,' says Target Zero belongs to everyone.”
Organizational and Cultural Context
The Target Zero launch took place as Shore Health's nurses had been working toward Magnet status for 5 years, achieving it in October 2009. Only about 5 percent of all hospitals achieve Magnet status for their excellence in nursing. The Magnet Quality Improvement framework is outcomes driven and encourages organizations to empower nurses, set high performance expectations, and become more patient-centered. Parker said, “A culture of nursing empowerment must be supported at the highest level and allow nurses to learn, grow, and practice to their full potential.”
During 2006, the full continuum of care had begun to be brought together under Parker, adding Patient Services to his CNO responsibilities. By 2009, acute care, pharmacy, home health care, rehabilitation, case management in the community, and hospice had become integrated under him. Through their horizontal restructuring, and through meeting, planning, and solving problems together, silos have broken down, teamwork has grown stronger, and staff members, Parker said, “think beyond their own piece.” A current focus is enhancing handoff communication and preventing readmissions.
Thus, prior to Target Zero, Shore's nursing staff were already using a QI framework, increasingly taking responsibility for patient outcomes, and collecting central line information that was sent to Infection Prevention. Parker believed the front line should drive process change and be free to innovate; he saw his role as making sure they had process, structure, and resources. “They can tell you the barriers. Our job is to remove them.” Bryan further elaborated the cultural context, “We are rural hospitals. We take care of our neighbors and friends and people we see at the grocery store. After their hospitalization, we will see them again at the YMCA or some community function.”
Performance Improvement Teams
In 2008, Shore had set up two task teams, one charged with implementing a VAP bundle, and the other implementing a central line insertion bundle and checklist. The teams had some success in reducing infections, but were discovering through the literature that there was more to do to get even better results. They realized they needed to develop a maintenance bundle.
The Target Zero launch generated the momentum for these teams to expand and to evolve into permanent performance improvement (PI) teams focused around specific HAIs. One would deal with both CLABSI and CAUTI prevention because they required the same interdisciplinary cast: representatives from all departments at both hospitals, including home health and hospice. The VAP team dealt only with ventilators in the ICU, and thus had a more specialized set of clinical members: ICU nurses, intensivists, pulmonologists, respiratory therapists, pharmacists, medical directors of IC, and pharmacy. Nurses and respiratory therapists led the VAP team, and front line nurses led the CLABSI/CAUTI team. A third PI team was formed to focus on hand hygiene.
Bryan, who had spent 15 years in staff development and nurse education, described the importance of thought leaders in a relational context. “Nursing is a lot about relationships, and I work through key thought leaders. We made sure we had thought leaders on our PI teams. They are the movers and shakers: they make things happen here, they know how to get things done. They are all over the hospital, some are front line.” Carroll added, “They're also the early adopters, the mavericks who are motivated to make change. We try and harness their passion on teams. We help them do it as a system and not just as one individual.”
The biggest challenge, in Parker's view, was creating the expectation that zero was achievable. “Nurses advocated for patients and got the rest of the team to buy into Target Zero. On a day-to-day basis, the process was led by Infection Prevention.” Bryan provided guidance in teams' literature searches and discussions but, she said, let them come to their own conclusions so that, “now they owned it, ran with it, and owned the success.” Carroll, whose background was QI, said, “These people have day jobs, they can't learn all these different methods. We steal from all methods, simplify them, make them user-friendly, teach the basics, and pull in tools as needed.”
The teams used the AHRQ Hospital Survey of Patient Safety Culture for everyone in the hospital to measure Shore Health's baseline. Each department analyzed their own results, drilled down to find the reasons for them, and developed plans for improvement. Teams mapped current processes; identified strengths, weaknesses and opportunities for improvement; and developed plans. They revised their standards and protocols according to best practices.
When they had begun seeking HAI bundles in 2008, the Michigan Keystone Project had been getting some press regarding their CLABSI success, and Shore Health had implemented their CLABSI insertion bundle and checklist. Now the CLABSI team developed a maintenance bundle and revised Shore Health's policies accordingly: dressing, daily assessment, chlorhexidine patch, changing lines inserted under emergency conditions, etc. The Institute for Healthcare Improvement had a VAP bundle that they implemented.
Shore Health was on its own with prevention of CAUTI, their most frequent infection, which they had tried for years to eliminate. The PI team concluded that the most important thing was to get catheters out as soon as possible. They developed a protocol that switched the default setting: Nursing could take it out as soon as possible, and an order had to be written to keep it in. This change required an extensive education effort with physicians and nurses, and took time to get through the medical staff and Medical Executive Committee. In the year since its implementation, Shore Health has had only four CAUTIs, down from nine in 2010.
Taking the show on the road had symbolically transferred ownership and responsibility for HAIs from belonging solely to the Infection Prevention Department to everyone in the organization. The transfer was expressed in Target Zero's tagline, “it begins with me.” Now Infection Preventionists provide data and guidance, but if there is an infection on a surgical unit, it is the unit manager and nurses who investigate why. They dig into medical records to see what could have been done differently, consider different products that could have been used and use every infection as a learning opportunity.
Education played a major role in spreading ownership of eliminating infections to every person in every department. Bryan made a presentation to Housekeeping, for example, that explained how their work impacts the patient. Bryan highlighted the different “wet times” of various disinfectant solutions they used. “I emphasized how important that was, that they are not just ‘cleaning'; they are preventing infection. That really engaged them.”
Publicizing data had also engaged staff. Shore Health tried several kinds of data and ways of presenting it before they found what spoke to people when Carroll graphed “days since last infection” for all three targeted infections.
Michael Tooke, MD, Chief Medical Officer, and Senior Vice President, whose oversight includes infection prevention, performance improvement and patient safety, believes that empowerment and ownership took hold because “we reinforce it over and over. Target Zero is everywhere; it's a very visible campaign. We publish and disseminate results. And we celebrate.” Any unit that completes 12 months or longer without a particular infection gets a party and their picture in the weekly newsletter and on the website. Senior management allots a budget for these celebrations. They are major events that reinforce the fact that Target Zero is a whole system effort in which every person in the organization must do their part to make it happen. Tooke continued, “The celebrations give them ownership: We did it. Our unit did it. And they don't want to be the one on the unit that breaks the string. We keep finding reasons to celebrate, like with the song contest.”
A contest for a hand-hygiene song generated 13 entries. The nurse with the winning song included every part of the organization in her lyrics, reinforcing Shore Health's theme that every area and every person has a part to play in keeping infections at zero. (The top three songs can be heard at www.shorehealth.org/target-zero, near the bottom of the page.)
Having fun about deadly serious things became a hallmark of Target Zero, especially around hand hygiene. During one campaign, when people were caught “doing the right thing” by a senior executive on rounds, they got a card, the card was dropped into a box, and a random drawing was made weekly. Winners got a Target gift card. A Christmas tree was decorated with gloves and hand sanitizers. A 2011 campaign entitled, “Ask me if I've washed my hands,” produced signs, taglines on badges, window stickers, pictures, posters and publicity. If patients and visitors could ask the CEO, CMO, and CNO if they had washed their hands, certainly they could ask other physicians, nurses, and administrators the same question and other, even more important ones, related to their own care.
In 2010, Maryland became one of the States in a new cohort of On the CUSP: Stop BSI, and Shore Health became involved. The health system had done a great deal of work by that time, and its HAIs were falling. Bryan noted, “We were using the five elements of CUSP and many of its tools even before CUSP began in Maryland.”
Shore Health educated staff in evidence-based practices and the “science of safety” using the CUSP program and incorporated the Learning from Defects process. Staff learned more about the importance of having layered checks and balances so that human errors don't reach the patients. CUSP teams were formed in the two hospital ICUs. Bryan explained the fuzziness in many people's minds about CUSP:
“We drew on CUSP elements and tools in creating Target Zero, and later we blended CUSP teams into what we had already been doing on the units. I think that is why so many of our team members have difficulty separating Target Zero from CUSP. Target Zero is a CUSP initiative with a different name and logo.”
The ICUs instituted daily rounds and morning briefings, and team members participated in the Collaborative's calls. Ryan Foster, RN, Nurse Manager for the ICU and the multispecialty care unit at Dorchester General Hospital (DGH), described how she experienced the value of CUSP:
“We had successfully implemented many measures in preventing CLABSIs before we joined the Maryland CUSP initiative, and the culture was already there, so it's not been a huge change. But CUSP brings the ability to network within our region and the nation, and learn from individuals who've been able to achieve great quality. You are able to collaborate with your peers in regards to struggles and successes. You hear about how someone else went down that road and made it work.”
Engagement with CUSP strongly reinforced what Foster also knew from experience. In her view, the most significant shift has been staff ownership of health care associated infections and use of evidence-based practices because, “if the staff don't own it, they won't make the practice change. But when they do, they will do what they need to do clinically to make it happen. The cultural and clinical pieces are completely intertwined. Target Zero is not just what we do. It is our culture.”
While the team had adopted the CLABSI bundle and checklist, a key cultural shift was apparent when the Medical Executive Committee (MEC) made it mandatory. Tooke commented, “The MEC is loath to mandate anything. But by providing the data, the evidence, we were able to achieve a cultural milestone. This was a big step for the MEC.” Target Zero empowered nursing staff to speak up and stop the action when physicians were not adhering to the bundle. Parker said, “Culturally, that's not an easy place to get to for nurses, but they knew they would be supported when they spoke up and advocated for their patients.”
Once that step was taken, other mandated protocols followed: a clinical pathway for sepsis, a Foley catheter protocol that switches the default position to getting it out unless there is a specific order to the contrary. The MEC also made consulting the pulmonologist mandatory for intensivists in the ICU to ensure that the ventilator bundle is complied with. Initially, some physicians continued their old practices, but when one of their patients contracted an infection, they were contacted about why they had not abided by mandated practice. It was, Tooke said, an educational process that “took some sorting out.”
Ingrain, Sustain, Expand
Every day is seen as a new day filled with opportunities for zero infections to occur. Bryan says, “It's not one or two things, it's a whole system effort. It's a lot of work to sustain it.” Daily communication between infection prevention (IP) and the front line staff keeps attention proactively on achieving and sustaining zero infections. Bryan said, “Erica (Disharoon, the other Infection Preventionist) and I talk with people on the front line every day. If we see a catheter that's been in for days, we start talking about that. We look at x-rays daily for people on ventilators. Are there changes we don't like to see happening? Sometimes bringing attention to things can make a big difference.”
Senior leadership deploys its resources to support Target Zero. When, for example, the team discovered an alcohol-impregnated cap that keeps ports disinfected, they were authorized to buy this more costly product because it saves valuable nurse time and reduces the risk of infection.
Shore Health continues to expand the scope of Target Zero. It has reached out to patients and families to invite them to ask whether staff have washed their hands. This emboldens patients to ask other questions. Staff members have met with nursing home staff and home equipment providers to enlist their attention on preventing infections. Shore Health launched the 100 Ways in 100 Days campaign to elicit staff ideas about how to eliminate HAIs. The campaign knits every part of the organization together working around a shared goal. As Tooke summarized, “The processes of achieving zero and keeping infections at zero has become “the way we do things every day.”
For more information about Shore Health's Target Zero campaign, please visit their website: www.shorehealth.org/target-zero/.