Small and Rural and Critical Access Hospitals (Transcript)

July 19, 2011

Operator: Excuse me, everyone. We now have our speakers in conference. Please be aware that each of your lines is in a listen-only mode. At the conclusion of the presentation, we will open the floor for questions. At that time, instructions will be given if you would like to ask a question. I would now like to turn the conference over to Deborah Bohr. Ms. Bohr, please begin.

Deborah Bohr: Hi, everybody. This is Deborah Bohr, and I’m a senior director with the Health Research and Educational Trust, the research and education arm of the American Hospital Association. And I am absolutely delighted to have about a hundred of you in the audience there listening to this call on small and rural and critical access hospitals and how they have been using CUSP to address CLABSI elimination and CAUTI elimination. The flow is going to be we’re going to have three presentations. You’re going to listen first to Denise Flook, who is the director of workforce development and infection prevention at the Georgia Hospital Association, and she’ll be joined by her colleague Lorna Martin, a patient safety specialist also at the Georgia Hospital Association. They then in turn will introduce two of your peers, Paul Frigoli in Wisconsin who is with a critical access hospital and Val Pfoutz who is with a small and rural hospital. Then we’ll open it up for questions, and then we’ll want to hear from you. So without further ado I would like to turn the first part of the presentation today over to Denise and Lorna.

Denise Flook: Thank you, Deb. We’re excited to be here today to share with our critical access and small rural hospitals how they might use CUSP, the Comprehensive Unit-based Safety Program, not only to eliminate preventable blood CLABSIs and UTIs, but also to use for any patient safety program, that this is the foundation for any quality improvement work that you might be doing. I work especially with our patient safety on infection prevention initiatives, and Lorna Martin works in Georgia. She’s assigned to work with our critical access hospitals and small rural hospitals as well.

So if go to slide 4, you know that quality and safety are key to hospital success. With now value-based purchasing, hospital-acquired conditions, and other value-based pay-for-performance coming down not only for PTS hospitals, but it will be coming very shortly to critical access hospitals as well. And not only just the Government payers, but our private payers as well are demanding efficient, safe care for our patients related to payment. The other part of this, though, is because our resources are becoming tighter and tighter -- both our financial and our staffing resources -- it’s going to necessitate hospitals to become more efficient and safer. And so we wanted to talk to you today about using CUSP for that purpose. If you’ll go to slide 5.

Lorna Martin: Good afternoon. This is Lorna. The challenge that we all have, not just about this particular subject, but in hospitals there is always a great challenge of how do we provide and sustain the highest quality and the safest care for every patient, every time in the current environment of diminishing resources. I know that for years we probably have done ourselves a disservice because we thought we would do the best that we could. But we now recognize that patients should receive the right care every single time. We can’t have a patient that doesn’t receive the right care. So that becomes a challenge for us because it’s hard to keep that momentum going. It’s hard for particularly critical access and small rural hospitals when the staff has to carry sometimes two or three different positions. It’s hard to remember how you need to focus each particular part. And the best way to do that is with CUSP. And as Denise goes on in a few minutes, you’ll see that if you make this a habit, which is the best way in the world to be able to keep your momentum going, then you can go forward. Your employees will have a better understanding of what it is they are responsible for. They will have a better understanding of how to do their job, even though their job may involve five or six different categories. You can have a better knowledge and focus. It’s easy to think that simply implementing a checklist is the path to better outcomes. However, changing culture is the key to sustain safety and improve outcomes for our patient. And that, of course, is where we’re going.

So we’re on slide 6 now, and this is a chart that the Johns Hopkins Research Group developed that I think is an excellent way to look at our safety initiatives. It’s got to be a two-part process that works hand in hand. It is a culture change. We’ve got to have that culture in on the unit level all the up to the executive and board of trustees. But we also have to make sure that we implement and we translate evidence into practice. So, we are basing all of our improvement efforts on evidence-based practices. Not any more what we’re used to doing, what I call “practicing by tradition.” This is evidence-based as you work through either CLABSI or the CAUTI initiative or other initiatives. We know that the first thing we want to do is ask “What is the evidence out there that we know eliminate preventable harm for our patients?” So the first thing you want to do is measure, where are you? You can’t understand where you’re going or where you need to go or create a target until you measure. From there, you want to work on the Comprehensive Unit-based Safety Program. And that entitles educating staff on the science of safety, identifying what Dr. Pronovost called “defects” or areas that you improve on — and that’s having the staff actually identify that. Assigning an executive to adopt the unit, so this is an executive-level partner who will actually work with you on your team for whatever improvement process you’re working for to not only be a cheerleader for the cause but also to be a facilitator and someone who can provide resources to you. Someone who can feed back the information to the senior executive team and board of trustees, perhaps, but also is one that will provide positive feedback to the staff level as well so they’ll know how important it is when the executives engage. You want to learn from one defect per quarter, meaning looking at whatever quality improvement things that the staff has identified and focusing on that for improvement. And then implementing teamwork tools that will help support that culture that you’re developing. So that might be TeamSTEPPS, it might be SBAR, it might be rounding -- a lot of tools that we’ll talk about in a minute.

And then on the other side is looking at how often do you harm patients and how do you know your patient outcomes are improving? But in order to improve that, you want to summarize the evidence in a checklist. We know that when we have checklists that are actually used -- not checklists that are on the chart and you’re just, “Yeah, yeah, yeah. I did that, I did that” after the fact -- but actually tools to remind everybody involved in the process of the evidence that you must do with every patient. You want to look at what your barriers are in implementing the evidence-based practices, and you want to get support to knock down those barriers to improve. You want to measure your own performance so you’ll know where you are, and you want to ensure that all the patients are getting the evidence-based practices. And this is where that checklist could be a way to audit or monitor whether every patient is getting those evidence-based practices.

So let’s talk about CUSP a little bit more on slide number 7. It does stand for the Comprehensive Unit-based Safety Program, and it’s a cultural intervention to learn from our mistakes or the harm that we’re doing and improve the safety culture on our units, and, like I said, throughout the organization, so we can sustain these. I hear so much from our staff-level nurses that I work with that very often anymore there’s so much going on with patient safety and quality and hospital-acquired conditions and everything, that every day there’s a new process developed sometimes by people that don’t actually do the processes. And on one week they’ll focus on core measures, another week they’ll be off on CLABSI, another week off on CAUTI, and if you look at the measurement it’s up and down. You see a lot of variability. Well how can we get rid of that variability and ensure that what we implement that’s evidence-based is fully implemented and, number two, that it’s sustained?

And so, if you look at slide number 8, the process intervention, the first thing you want to do as far as our culture and creating the unit-based safety program is when you create a team, you want to improve and reinforce good cross-disciplinary communication and teamwork. And that includes when you’re looking for something to improve upon that your team is cross-disciplinary in nature so everyone can be involved in the development of the technical practices that you do, but also that everybody supports that communication and teamwork. We want to enhance the coordination of care because that’s where a lot of times we fall down. There’s fragmented care. We want to address overall patient safety. So not just whatever program we’re working on or whatever issue we’re working on, but every day people come to work and at the top of their mind is how do we keep our patients safe today? No matter what their diagnosis, no matter what their procedures are that they may be having, but it’s at the top of everybody’s mind. And also working toward a helping unit collaborative-type culture. So people have each other’s backs, where you are supporting each other, you remind people if you see a lapse in practice in a positive way, and you support that teamwork and communication.

And then when you’re looking at your technical side, when you’re looking at reduction of the improvement process, so if you want to reduce your BSIs you want to go back and look at the best-evidence supplies. Is there a particular catheter that perhaps evidence has shown is better than another one? And you want to have those supplies readily available at the bedside, if possible, but certainly readily available on that unit on a cart or a box or whatever so it’s all together so nurses and physicians aren’t running all over the place trying to gather supplies. And that way you know the supplies that you have identified as the best-practice supplies are there to use. Again, we talk about using checklists and protocols so we have consistent application.

So the CUSP steps on slide 9, again we want to develop that team. This should be a unit-based initiative. So on that particular unit, even if there’s multiple units, you need to have a unit-based team that includes the unit manager or charge nurse or director, should have staff nurses definitely involved, any other staff. So if you’re working on ventilator-associated pneumonia, you definitely want to have your respiratory therapist there, must have physicians involved because they are key to that. If you have interns and residents, you can include them. You should have your senior executive-level person on that team and any others that you decide that you need. We talked about the executive. You should educate the staff on the science of safety. And there’s the link there to that. It’s on the On the CUSP: Stop HAI Web site that you can download as well. That is the basics to what we’re doing when we talk about the science of safety. And all of the staff on the unit and all involved in the teamwork and the senior executives should see that presentation by Dr. Pronovost. You should then next identify and prioritize defects, and there’s a staff safety assessment form that you can download off of that site, and that link is actually at the end of the presentation. You want to implement the teamwork tools like we talked about: SBAR, TeamSTEPPS, teamwork tools, rounding, the daily goal worksheet. Provide timely feedback, and I’m talking about monthly feedback. You can do weekly. You can do every time there is a, let’s say a blood stream infection occurrence or what you’re trying to prevent occur, that you provide feedback to the staff, naming the patient and learning from that defect. So you do kind of a root cause analysis light to look at and investigate was the evidence followed? If it wasn’t, why it wasn’t, are there barriers that we need to identify with that?

So if you go slide 10, I love this chart that kind of summarizes the whole pathway, flowchart. So if you look at the top, the first thing you want to do is assemble your team, partner with your senior executive, and gather your baseline data. Where are you? What is your rate of blood stream infections on this unit? What is your CAUTI rate on this unit? What is your fall rate or your pressure ulcer rate or whatever? Again, on the left hand side is the technical flowchart where you look at those practices that will prevent harm. You’re going to use your evidence-based practice. You’re going to do a system analysis. You want to process once you get your evidence and choose what you’re going to do. Then you want to develop the process so it’s a reliable process that will be done every time with every patient. And you can use whatever quality improvement tools that you’ve been trained on and you use in your facility. It doesn’t matter. You can do PDSA. You can use Lean Six Sigma. You can use Reliable System Processes. You can use the tools and the transforming care at the bedside. What tools you do to actually create the process and create how nurses or others will implement these practices every time that is determined by the organization. And then you want to educate everybody on where you’re going. So you want to educate on the evidence. “This is the evidence. If we do this, if we prevent X number of blood stream infections, then we will save not only patient lives, but we will save this much amount of money,” which is so important to a hospital nowadays. It’s always good to have professional organization recommendations to back you up because physicians will want to see that and then a bibliography if you might have it. And then the implementation and sustaining is creating the checklist and having it available, policies and procedures on how this process will be done, any protocols that can be nurse-driven, perhaps, protocols that the medical staff has approved. You want to have a person that’s monitoring how you’re doing and then, again, feedback to the staff on that unit. In CLABSI and CAUTI, you can create banners that say, “We’ve gone 120 days without a catheter-associated blood stream infection.” Or, “We’ve gone 20 days without a patient fall.” Whatever it is, the staff will know they’re doing a good job and what they’re doing is working.

And then on the CUSP side, we want to again educate on the science of safety, having an attendance sheet. We want the staff to identify the defects. So you would use that safety assessment form and identify the hazards with that process. What are the barriers? You want to educate your senior executive. You want to use the learning from defects so if you do have an occurrence of the defect or you have a blood stream infection or whatever, you want to use the toolkit that’s available online again and do a root cause analysis to learn. I know we’ve had several hospitals do that, and they’ve learned it hasn’t been an implementation issue, it’s been a maintenance issue, and maybe there’s a problem with the particular supply that you have. And then the teamwork tools, using daily goals, shadowing, a morning briefing on the patients and where you are: Were there risks off of those particular patients on the unit with the staff that’s working, the oncoming staff? Using a team checkup tool, to monitoring the progress of the teamwork, and then things, again, like TeamSTEPPS.

Number 11, CUSP is a continuous effort. And this is something that should be woven into the fabric of your quality improvement program. This is your foundation. So you want to add that into your foundation. You want to hardwire that into your organization. Many people have taken that science of safety education and DVD and put it on their intranet education center. They include it in new and annual orientation for their staff. And then once you’ve indentified a defect, then you share and post lessons that you’ve learned. So even within your hospital, if you’ve piloted something on one unit, you want to share the lessons learned throughout the hospital. And you have to decide again what in your organization is your best quality improvement and teamwork tool and, again, the feedback.

So let’s walk through very quickly outside-of-the-box thinking because many people have used this for CLABSI and CAUTI, but let’s think of something different. Let’s think about how you can eliminate hospital-acquired Stage 3 and 4 pressure ulcers. So you want to develop a team including your staff nurses if you have a wound care consultant or nurse, physicians, you want to include your patient care techs, your nursing assistants here definitely because they’re involved in this. You want to gather your baseline data. You want to have a team meeting with this core group, educating on the science of safety, sharing the data with them, and creating goals. The goal should be zero. We want to eliminate preventable Stage 3 and 4 pressure ulcers. You have somebody research the evidence-based practices -- there’s a lot out there on eliminating pressure ulcers -- and bring it back to the group. And so you want to then develop on your technical side what that process would be. So that might include, on slide 12, an example of how to do a comprehensive skin assessment and make sure that’s done on every patient. Standardize the pressure ulcer risk assessment. So you standardize who may be at high risk for those ulcers. You look at your care planning and implementation to address those areas of risk, and then you implement other evidence-based practices as needed. And from there you would go ahead and implement that. You would educate all of the staff, everyone included, and you may want to use one of the snorkeling, or the reliable processes. You do it with one patient for one shift with one nurse and see if it works, if it does work or you tweak it. And then when you’re ready to, you take it out to the unit and you educate everybody: Physicians, patient care techs, everybody involved in that process, and then you start monitoring it.

So, again if you look at slide 13 it’s a summary of using CUSP, and just think about on the right hand side, those things are consistent all the time. Your CUSP piece of that, for instance with pressure ulcers under daily goals, when you’re looking at a daily goal for every patient on that unit, you would ask the question “Is this patient at risk for a pressure ulcer?” And if they are, then you talk about how can we prevent that today, meaning you would make sure that you would move them every 2 hours and other things like that. For CAUTI or BSI you would ask “Is this catheter necessary today? Is this urinary catheter or central line catheter still necessary today?” So you look at those things, and you adapt what you’re doing with the CUSP. But the technical piece is what you’ll build out for the issue that you’re working for. So again, if you’re looking at falls, you would use the evidence-based practices to prevent falls. If you are doing CLABSI or CAUTI, you would use the evidence there. So that’s kind of a flowchart to kind of help you through that process.

So what this really takes to change culture and to envelop CUSP throughout your hospital, but especially on the unit where you have the staff nurses, the staff on that unit, take accountability and responsibility for their safety of their patients. It’s not just someone feeding them information every month and saying “Doing better,” it’s actually every day they think about how they can prevent harm in their patients. Lorna, I’m going to let you wrap up.

Lorna Martin: Okay. It does go back to leadership. As we know, everything goes back to leadership on all levels. It’s easy to say that we want to engage the employees, and I believe that most all employees feel that they are engaged in their work. That because this process is so important and being able to get the patient taken care of correctly every time, we have to have commitment, communication, and that engagement. We also need to provide education. Ask the staff what they need. Is there something that has been missed in their training? Is there some process that they could investigate to see if that process is causing them to spend too much time? Provide resources for them. Let them ask many questions. Be visible and transparent. Don’t ever try to hide some sort of problem from staff because they’ll know it. Feedback is very important. Receive that feedback from employees and give feedback to the staff. Include your physicians in this leadership and commitment and feedback. Investigation and ownership of outcomes and improvements; this is a crucial piece because we all need to own this process. Our process is a good process. It keeps the focus and it prevents us from making mistakes. So as you see on that next slide, keep the focus. There are challenges ahead but everyone must not lose sight of our North Star — the patient -- who must be kept in the center of all we do. Your commitment, leadership, and persistence is an essential key to patient quality and safety.

Denise Flook: Thank you, Lorna. If you’ll go to slide 19 you’ll see — we do have references on slide 17 but on Slide 19 is the On the CUSP: Stop HAI Web site that I talked about that you can find many of these tools, and your State Hospital Association quality director can help you as well. So, let’s hear how hospitals, both critical access and small rural hospitals have actually implemented this CUSP process within their organization. So I’m going to turn it over to Paul Frigoli who’s the quality director of Grant Regional Health Center in Lancaster, Wisconsin, which is a critical access hospital. Paul?

Paul Frigoli: Yes, hi. Good afternoon, everyone. We are a critical access hospital located in the rural southwestern corner of Wisconsin. And as most of you that are critical access hospitals represented in the call, we have 25 beds, and we do have OB. We do have an operating room. We do have perioperative services. So we do wear a lot of hats. Our nurses work in two units, sometimes three units, and they have to be specialized in everything. So when the CUSP program came about, especially with CLABSI, we decided to investigate what it was all about. And so we joined the collaborative, and we got together a team. We have very low volume. We can go for several weeks with no central lines, and then all of a sudden we’ll have several. We do insert central lines. We don’t have a high volume of them, and we don’t have an intensive care unit, so we definitely don’t have the intensive care pieces. But we wanted to get involved, and we wanted to make sure that we kept our infection rates down to zero. That was our goal. So we set up a team, and I helped facilitate it as the quality director, but we made sure we had nurses represented from the various areas, including the operating room. We also invited our materials management person to join us because he would be the one that would help order our supplies and that kind of thing. We had our pharmacist there. We also had a PA that works in the emergency room. We thought maybe he would help us with giving us some medical staff representation. We invited our vice president of nursing from administration to come with us. We also had our infection preventionist. And then we had somebody from lab and somebody from radiology, only because the radiology folks wanted to be involved in case they end up being part of the process at some point.

So we got together, and we started talking about where we are and what we’re doing. We watched a video and decided that we would prepare a bundle as it was recommended because there was a lot of inconsistency, whether it happened in the day or at night or on the weekend or which position was around. There was so much inconsistency in our practice. So we made a bundle. We got one of the plastic tubs, and we put things in in the order in which you’re going to use them and the very first thing on the top is the checklist. And in every bundle we also have a QA sheet, as we call it. It’s a sheet that says, “Did you follow the guidelines? Did you use this? Did you use that? Did you remember to use the checklist?” That’s the first question on it. And then that form circulates down to me in the quality office. And we implemented the bundle and had a few rough spots, of course, at first. Something was missing. The doctor didn’t like where that was. He couldn’t find this. So then we rearranged the bundle and made it so that it worked better for them, and we implemented it with a backup bundle in materials management for us to get in case we had to swap it out before materials could do it for us if it was after hours or something.

And it just worked beautifully. We started entering our data into the Keystone Project, and we had a lot of support. We have a wonderful supportive department that works with us in the State of Wisconsin. So we linked up with all of their things and their projects and attended their training sessions, and we’ve been able to keep our rate down to zero. So we’re very proud of that. We talk about it a lot. We keep it in the forefront. We don’t meet anymore every quarter; we were for a while. Now what we do is we email meet. We just email each other among the team members to see if there’s anything to talk about. And then, in the quality office, we carefully monitor those sheets that come through to make sure that we are still following the protocols. If we slip up, then we talk about it. We haven’t had a slipup in several quarters now. And I do put out a report card. We put out numerous quality report cards throughout the hospital, but this shows up as an indicator.

So interestingly enough, we liked the CUSP process really well. It just seemed to fit our culture well. So we came up with another initiative that was totally unrelated and perhaps doesn’t apply in some institutions, but we had a lot of confusion about MRSA patients or MDRO patients that would come into our facility because not everybody was consistent in the isolation especially. Some physicians didn’t even agree with other physicians on whether to isolate patients or not, and it became quite confusing. So we decided to use the CUSP process and put together a team. It was a lot of fun. People had had fun with the CLABSI team so they had fun doing this. And so this time we had housekeepers involved. We had a different group of people that came, and we started working on what do we know about MRSA; how much of it is in our facilities; how many of these diseases come through our institution; and when they do, do we isolate them appropriately or do we have problems? So we ended up getting our baseline data and finding the confusion was down to the signage. Housekeepers had a lot of confusion. Dietary had confusion about whether they could go into the room or not. And by putting this model to work, even though it was not intended necessarily for this, we were able to come up with a wonderful program.

We now have standardized the way we handle patients with an MDRO. We now have some little key things that are clipped to our name badge. They’re like a second sheet behind our name badge that has a quick reference of “If this organism comes into the facility, this is the kind of isolation you must institute.” We now have a real fancy — it’s homemade — but it’s a fancy policy on our electronic drive where you can get in there and you pull it open, and you look up the disease, perhaps something strange that you don’t know anything about like aspergillus or something. You click on it and immediately it tells you what kind of isolation it is, what you need to do, how do you limit your visitors, and what’s real important to tell the family. And it just gives you a snapshot right away, five little things, so that you know exactly what you’re dealing with when this patient comes into your facility. We have really reduced the amount of confusion. We came up with new signage to put on doors. We now have a standardized system. Now our patients are all treated the same way according to their disease process. Our physicians have bought into this because we consulted them from the beginning, and they have seen that we’ve taken this very seriously.

So our new frontier now is the CAUTI initiative. We’ve signed up with NHSN, of course, and we’re feeding our data into that, and we’re getting ready to go. In the critical access hospital, we don’t have as much automation as other places. We don’t bill the same way as other institutions. Therefore, we don’t have access to catheter days very easily. So it becomes more manual, and we’re trying to figure out how that will work. But we already have our CAUTI team ready. We’ve already had a meeting, and we’ve started the process. We do have quite a few catheters on our units. We have a large nursing home population that uses our acute care services, and many of them come in with a catheter in place or need catheters. So this is going to be a challenge for us, but we’re really ready to go with it. And I cannot emphasize enough, even though we’re small and our focus is totally different, the whole CUSP program has been a lifesaver. It has been, just as Denise was saying earlier, it has totally become the platform on which we do our quality improvement on the clinical level. We will never go away from it. It just seems to work well for us. We’ve bought into it 100 percent, and even though our numbers are small, and we have very little data to show on the big scheme of things, on our level here in our institutions and the community we serve, we feel like we’re providing much safer and much more excellent care. So I thank the people that have organized this program and Dr. Pronovost, and all of the literature that we’ve been able to use has been extremely helpful.

I’m going to stop here because I know we’re going to leave time for questions at the end, and I’m going to now introduce my colleague Val who’s the director of ICU in Dixon, Illinois.

Val Pfoutz: Thank you, Paul. Yes, my name is Val Pfoutz. I’m the director of the ICU at KSB. And KSB is an 80-bed hospital, so pretty small. And the ICU is a six-bed unit. We’re in cohort two in the CAUTI project, and actually to be honest with you, it’s going really smoothly. Of course with six beds, it’s very easy to get the data as far as number of patient days and number of Foley days. We just recorded and actually submitted all of our information for the month of June. We had 151 patient days and 91 Foley days, and between the charge nurses we generally have, our patient-nurse ratios are pretty good. We have two patients per nurse, so usually we’ll have three nurses staff the shift. So between the charge nurse, myself, and Mary Helfrich, who is our infectious disease nurse, we just check the book to make sure that the catheters are recorded. And we used the tool, I think, that we got from the project as far as recording the catheters and the indications and the insertion dates, removal dates, things like that.

Before we did start this project I had all of the staff watch the science of safety video. That went over very well. We right now are finishing up on the survey, there’s that safety survey. And I think we had 40 people do it, but right now we’re at 62.5 percent completed on that, which is acceptable because I think 60 percent is the minimal amount to be included in that. That survey will be done on the 29th of July. So we were very happy to report in June we were at zero catheter-associated urinary tract infections. And this really has gone pretty smoothly. Like I said, being a small hospital starting in ICU, it’s pretty easy to collect the data and monitor that really well. The nurses on the floor have really just taken a better awareness of catheter-associated urinary tract infections, and the number one question that I am reiterating to them is, “Is this catheter necessary to be in my patient?” So just an all-new awareness, too, if the tube is necessary and things like that. So that’s really all I have to report from our side. It’s going really well so far. Thank you.

Deborah Bohr: Thanks so much Val and Paul and Denise and Lorna. This is Deb, and what I’d like to do now for the next couple of minutes is turn it over for questions. And operator, if you can give any instructions for people in terms of asking questions that would be great.

Operator: Thank you. At this time we will open the floor for questions. If you would like to ask a question, please press the star key, followed by one key on your touchtone phone now. Questions will be taken in the order in which they are received. If at any time you would like to remove yourself from the questioning queue, press star, two. Again, that is star, one now to ask a question.

Deborah Bohr: And operator, while we’re waiting we can also have people, if they don’t have a question but they have something that they’d like to share, both in terms of how they may be applying CUSP, any barriers, successes, or any insights they’d like to share that’s appropriate, too, during this session.

Operator: Ladies and gentlemen, again that is star, one now to ask a question or make a comment. We have a question from Christa Iler with Holton Community Hospital.

Christa Iler: Hello everyone. I just wanted to say, Paul, I didn’t catch your name or the facility that you’re with, but the work that you have a gone through with the infection control and the MRSA patients is something that we are kind of working through at this time, and it sounds like you’re much further down the road than we were. I wondered if you would be willing to give us contact information, or if they could forward contact information and you could offer us some guidance as we go through that process.

Paul Frigoli: Yes, this is Paul. I would be delighted to help you, and perhaps our facilitator could send out my email address.

Christa Iler: That’d be great. Thank you very much.

Operator: We are holding for questions or comments at this time. Please press star, one now to ask a question or make a comment.

Deborah Bohr: This is Deb Bohr, and the person who just asked the question of Paul, could I ask you to email me your name and email address and I’ll get that to you? My email is D as in Deborah, B as in boy, O-H-R at A-H-A dot org. And that number can be used by any of you who may have some questions or statements you’d like to make following this call. And thank you, Paul, for offering to have that contact information shared with folks.

Operator: Okay, we have a question from Jayne Heede with Wing Memorial Hospital.

Jayne Heede: Can you repeat that email? You said it too fast for me to get it down.

Deborah Bohr: Sorry. It’s D as in dog, B as in boy, O-H-R at A-H-A dot org.

Jayne Heede: Thank you.

Deborah Bohr: You’re welcome.

Operator: Okay, we have a question from Jayne Heede with Wing Memorial Hospital.

Jayne Heede: No, I was just muting.

Operator: Okay, thank you.

Jayne Heede: Sorry.

Operator: Ladies and gentlemen, the lines are open. If you would like to ask a question or make a comment please press star, one now.

Deborah Bohr: Well, this is Deb again. I think one of the things, while we’re waiting for anyone with any questions, is I would like to repeat what I heard both from the presentations. I think from Denise and Lorna we learned about the fundamentals of CUSP. I love the fact that, Denise and Lorna, you applied CUSP to another example which was Stage 3 and 4 pressure ulcers, talked about the importance of leadership, the importance of transparency and never hiding your problems, feedback, investigation, and ownership of outcomes and improvement, and keeping the focus and having the patients be the North Star. So I think that’s very, very helpful. I appreciate you putting the Web site up which was There’s a number of resources in there about CUSP in general and then specifically for CLABSI elimination and then for CAUTI elimination.

And then from Paul I think we heard how you got everybody on board. You had a goal of zero, which is what we’re asking everybody to do. You talked about, very practically, how you’ve got a QA sheet and then ordering the items in the plastic tub to be like your cart such that it makes logical sense in terms of order of use. Again, you’ve got the rate of zero which is great. It sounds like you’re very much in sustainability mode where you are tracking the numbers through the checklist and the QA, you know what your rates are so that you know they’re staying at zero, and you’re putting this on a report card and I think it’s fabulous that you’re now applying CUSP to MSRA and MDRO.

And then in terms of listening to Val, and it sounds like, Val, you’ve had no bumps in the road and you’ve been seamlessly applying CUSP to CAUTI elimination and that’s going really smoothly. Are you sure there’s no warts or any little barriers that you came across that you can share with us, or has it really just been very smooth?

Val Pfoutz: No. Well we’re just trying to build a baseline right now. There are the occasional patients that fall through the cracks as far as myself or Mary will record them when really we want the nurses to be filling out this paper and recording it, but like I said we’re just more eyes to catch all the patients so that nobody slips through the cracks. So I guess that is kind of a barrier that we’re kind of seeing. It would be nice if the nurses would remember every single time to put their name in the books so we could record it, but we do, we just walk around and make sure that they’re in there for sure.

Deborah Bohr: Great. Operator, are there any questions?

Operator: Yes, ma’am. We have a question from Dee Anderson with Central Baptist Hospital.

Dee Anderson: I’m looking for a good video or DVD to show physicians and practitioners the correct insertion. I’m having trouble with people remembering the right order or proof that we needed to be doing this. I had trouble with a physician last week and the IC committee team recommended that we actually make him review a PowerPoint, we have, take a test, and then I had the idea of if we showed him a visual maybe that would help. And I had trouble finding something that used all the components of the bundle or in the right order. So I didn’t know if anybody else had something already made or knew of one.

Deborah Bohr: This is Deb Bohr. I know that there is one insertion video that I think is available for charge. But I also know that there has been a JAMA, and I’m recalling what Sanjay Saint told me once about two videos, one for female insertion and one for male. What I would like to do is if you can email me, anybody on the phone who is listening to this conference call, if you can email me again at D-B-O-H-R at A-H-A dot org, let me see what I can find out for you in terms of either free videos and or videos that cost money, and I will be sure to get that out to you. And I can also see if they are not posted on our Web site, we should do that and point you to where that is on our Web site.

Denise Flook: Are you talking about urinary catheters or—

Dee Anderson: No, no. Central lines.

Denise Flook: Okay. That has been the discussion on our call, and I was just looking on the Web site to see if they have posted anything under resources because I know we’ve talked about that a lot.

Dee Anderson: Now I haven’t looked this week, but I could not find anything.

Denise Flook: Yeah, I don’t see one either. And we had actually asked Johns Hopkins if they might develop one, but I don’t think they have. You might contact Melinda Sawyer at Johns Hopkins.

Dee Anderson: Okay.

Denise Flook: Do you have her email address?

Dee Anderson: No. Is on the Web on there?

Denise Flook: I don’t know if it’s on here or not.

Deborah Bohr: Well you know what we can do, why don’t you let me triage that, and I’m sorry we were talking about CLABSI and I was confused. But there is a video for and I’m blanking on how much it costs. But if the speaker can email me at, I can follow up with Melinda and a few other people at the back of the office.

Dee Anderson: Okay, that would be wonderful.

Deborah Bohr: Okay. Thanks Denise for pointing out that I was talking about the wrong thing. So sorry about that.

Denise Flook: When you said, “Male and female,” I was like, oh, wait a minute.

Deborah Bohr: Yep. Deb’s off track. Okay.

Denise Flook: That’s okay.

Dee Anderson: It’s refreshing that somebody besides me is confused from time to time.

Operator: We have a question from Dela Lin with the State of Hawaii.

Dela Lin: Can you guys hear me?

Deborah Bohr: We can, Dr. Lin. Go ahead.

Dela Lin: Hi, Deb. So anyway I was very pleased to hear the presentation by the person from Wisconsin who said the CUSP has been a lifesaver. So, thank you so much for that presentation. And I wanted to make a question to the group. I wondered whether any of these smaller hospitals have had a chance to kind of look back and see exactly how much have they had to invest in CUSP, making sort of a return on investment argument for, not in terms of the dollars saved of preventing the infection because I know we have that opportunity calculator available. But before that, going to a small hospital and saying we need to make the investment for quality, I think that’s something we’re all a bit struggling with. Employers are struggling with, health plans are struggling with, and I just wondered on the frontline whether any of these smaller hospitals have been able to do that?

Deborah Bohr: Well, this is Deb. That’s a great question. Paul or Val or Denise? We’ve also got Marie Cleary-Fishman and Abby, both from the Illinois Hospital Association. Have you as State leads gotten any feedback from your facilities in terms of time and maybe hard cash investment? That’s what you’re referring to, right Dela?

Dela Lin: Yeah. So I mean we, from our standpoint, are working on looking at it from a fairly large hospital trying to look back now after 2 years and see exactly what the investment is. But sometimes it’s hard to track it, and I do hear from some of the smaller hospitals the whole thing Denise was saying at the beginning. Rare resources, what are we going to do, how do we get that leadership attention, and do we have any examples now having been in this CUSP work for a couple of years of hospitals who have been able to go back and say, “Okay. This really cost me this many FTEs, this sort of time investment,” and whatnot so that we can actually share that with them.

Marie Cleary-Fishman: This is Marie from the Illinois Hospital Association. And I’ve only been at the Illinois Hospital Association for 7 months so I don’t have much data to go on based in that timeframe. But I think one of the reasons that we — at least it seems to me — that we struggle with that is a little bit because we’ve sort of approached CUSP from the perspective of it associated and related to CLABSI and CAUTI. And so I don’t think we’ve necessarily tracked data very well on just CUSP implementation alone and the resources that might be involved in that. And actually one of the reasons that I was so glad to see us take this approach with this call is that one of my questions — and certainly hospitals can let me know aside from this — but one of my questions really is around what is needed more for hospitals in order to really put CUSP out there more on its own and as a real methodology, sort of like PDSA or some of the other quality improvement methodologies we use. So that we do get more of a robust culture built around using CUSP, and that in order to target the unit-based improvements, a lot of the time we have some system-wide kind of approaches or hospital-wide approaches to performance improvement, but I just haven’t seen CUSP sort of take hold in that same way. And personally having come from trying to work on quality from an eight-hospital system, to me CUSP would be a really, really useful tool to target the unit improvement. So I know that doesn’t help answer your question, it just sort of raises more questions, but I think it might be important for our discussions going forward.

Deborah Bohr: Well, this Deb. And, Dela, I want to thank you for that excellent question. All the questions have been good, and then Marie for you to amplify I think what Dela’s asking and how do we get CUSP hardwired and what’s really involved in that hardwiring, whether it’s additional FTEs, etc., in terms of building a more robust culture. And I know we’re getting close to the end of our time together but, Marie and Dela, I think that was a great segue.

What I’d like to do at this point is ask the participants on the call what subject matter they would like us to do in a quarterly small and rural and critical access call. Does anybody have, beyond what’s been discussed today, are there other critical access and small and rural hospital ideas you’d like to have explored? I mean, for example one idea might be to have Paul come back and really talk about how he’s applying CUSP to MRSA and MDRO. Or asking one of our State leads like Dela or Marie or Abby Radcliffe or Denise to come back and talk about another aspect. But I’m talking too much. I need to be silent. Anybody out there would like to put some agenda items for a future supplemental call on the table for us to consider?

Dela Lin: Deb, this is Dela. Can you hear me?

Deborah Bohr: Yes.

Dela Lin: Well, let me just throw something out while people think. I’m thinking in terms of the rural hospitals, one of the things that may be a struggle is that their denominators are often very small, and how do they manage that conversation? Are there different ways to look at displaying the data, working with the data? I know we’ve talked about how many days between having your last infection as one way, but a lot of what they have to do when the quality managers have to speak to the leadership and the board is that they’re looking at how many infections per thousand catheter days for CLABSI. And if you only have 20 catheter days in a month and you get that one infection in a whole a year, all of a sudden your data point is very high. And so I’m just wondering if that might be something that would be of use for the rural and critical care hospitals.

Deborah Bohr: Great question. Any brave souls out there, would you like to have that be a future discussion topic? [Silence]

Dela Lin: Maybe not.

Deborah Bohr: Maybe not. I know one of the things that we’ve talked about is if you do treat every CLABSI, because the numbers are getting low, if you treat each one as a sentinel event then the conversation is less about percentages or rates, and it becomes a discussion about the investigation of that sentinel event.

Dela Lin: Right. And I think we do that from our level in terms of the quality. I’m thinking in terms of when these folks actually have to then present the information transparently to either the public or the NHSN or to their leadership where there’s sort of a defined metric. And now they have to kind of rationalize, if you will, their data. And I would rather it not be a rationalization, but I was just wondering if there’s some best practice about this.

Deborah Bohr: Good point. Well, let me ask the group if I can as rapidly the sands of the hourglass are running out: Would it make sense at some future time, maybe later in the fall, to do an office hours that was pretty open? And we would have some State lead and national faculty be available for small and rural and critical access hospitals to dial in and talk about their challenges and or successes and insights and really have it sort of be an open mic kind of sharing session. Is that appealing to anyone?

Operator: Ladies and gentlemen, you can press star, one now to make a comment. We have a comment from Diane Waldo with Oregon Hospital Association.

Diane Waldo: Hi. Good afternoon, Deb. This is Diane Waldo.

Deborah Bohr: Hey, Diane.

Diane Waldo: Hi. I think that your concept of the office hours is a great idea, and I also like the idea of maybe a quarterly call as well so there’s a couple of options for folks. I wanted to tag on to what Dela said as far as we have a number of critical access hospitals in this State, and sometimes to get them engaged when their volumes are so small, we need a better marketing strategy, I guess, to help plead the case. It’s like, ‘”Well we have so few of those, why would we bother putting investment time, money, and resources into developing a CUSP strategy?” even though it can be applied to other options or other scenarios. So it’s that return on investment that she had kind of started the conversation with. And I think our smaller hospitals struggle with that all the time. There are a number of quality improvement opportunities for them that come across their plate. How do they pick the ones that are valuable when they really need to be doing probably more than less, but it’s that small volume that is an issue.

Deborah Bohr: Good point.

Operator: Thank you. Our next question or comment comes from Eva Payne with Wills Memorial Hospital.

Eva Payne: Hi, I was just wanting to say I would appreciate those suggestions you offered just earlier, both of them, although I didn’t answer the first time, but both of those would be helpful to us about the small denominators and other tools like that that we can work on to make this more user friendly for us or help us to present it so our numbers don’t look so bad.

Deborah Bohr: Well thanks, Eva, for speaking up and that feedback’s helpful. Thank you. We can make that happen.

Operator: Thank you. Ladies and gentlemen, again star, one now to ask a question or make a comment. We have a question or comment from Kim Gilbert with Electra Memorial Hospital.

Kim Gilbert: I think the office hours is a good idea for us. If anybody read in the JAMA for the July edition, I read it this morning and it was an article and a study on the quality in patient safety within the critical access hospitals and how it is less than it is in non-critical access hospitals. So I think it’s a good idea that we do meet quarterly and we have that opportunity to make those calls and get information from others.

Deborah Bohr: Thanks so much, Kim, for letting the group know about that article. And I will look that up. If anybody would like that reference, I can have that looked up in the next couple days and, again, you can email me. I am mindful that we’re past the time, and I will talk to the State leads on this call who I want to appreciate. Thank you so much to our faculty, Denise, Lorna, Paul, and Val, as well as to Abby Radcliffe and Marie Cleary-Fishman who helped pull this program together, as well as Jill Hanson in Wisconsin. And Dela and Diane, I want to really thank you for calling in and providing some really good feedback and instructions. And I think what we’ll do then is figure out when the next quarterly call can happen, and we can really address the suggestion about how to present when you’ve got such small denominators and then have open mic kind of office hours where people can talk about issues. So if anybody again would like that July JAMA article, we’ll also post it on the website where we’re trying to build out a small and rural and critical access section. But if anybody would like to have that citation more immediately, please email me at This discussion and the PowerPoint slides will be posted in a couple of days on the project Web site, which is And I just want to appreciate everybody for your time today. Thanks so much, and have a great rest of the week.

Denise Flook: Thanks, Deb.

Kim Gilbert: Bye, Deb.

Deborah Bohr: Bye.

Page last reviewed April 2013
Page originally created April 2013
Internet Citation: Small and Rural and Critical Access Hospitals (Transcript). Content last reviewed April 2013. Agency for Healthcare Research and Quality, Rockville, MD.