The National Project Team (NPT) learned several lessons in doing this work, both through its own experience working over four years with 46 States and regions, as well as through in-depth interviews conducted in May and June 2012 with 11 State leads.
Implementation Challenges
State Level Challenges
States that struggled the most with the project were those that joined the final cohort. These States had the lowest number of recruited hospitals and were States/regions with limited-to-no dedicated quality improvement staff and very limited experience in running State/regional quality improvement collaboratives. The low number of recruited hospitals reduced the opportunity for peer learning and provided less impetus for State leads to focus more attention on the initiative in the State.
A key feature of successful States was the ability to do one-on-one counseling and site visits to hospital teams. The lack of staffing in some States impeded their ability to do this necessary work. Another important challenge for some States was the lack of an effective quality council in the State staffed by hospital leadership. Such councils have played an important role in successful States by keeping the hospital leadership engaged in this work and accountable for achieving results. In more successful States, hospital CEOs had more experience in "backing up their staff" to create policy and practice changes, such as empowering nurses to stop physicians when sterile technique had been breached, and had board-level dashboards on which CLABSI data was routinely reported and scrutinized. Many of these States also had hospital association executives capable of motivating the executive leaders of hospitals to drive improvement within their organizations. Successful States also were more likely to have made zero CLABSIs an explicit improvement goal. All States had a difficult time getting their teams to use the monthly TCT. Teams reported to the State leads that the monthly data collection was too frequent and found the tool too static in terms of asking the same questions about the early implementation stages of CUSP.
Hospital Unit Challenges
All the States that were interviewed emphasized the importance of the engagement of senior hospital leaders. The lack of senior executive engagement was viewed as a critical missing element in teams that were less successful. The absence of visible and supportive physician and nurse champions was also a factor for less effective teams. Staff turnover was an equally important feature of struggling teams. Every State lead, whether from a high-performing State or a more challenged one, indicated turnover was a significant barrier.
Other challenges included the lack of dedicated, protected time for team members to do the CUSP work and/or collect CLABSI rate data and submit it to the Care Counts database. Some teams viewed On the CUSP: Stop BSI as just another quality "flavor of the month," or focused solely on the technical side of CLABSI intervention without paying attention to CUSP. Teams in most States undervalued the monthly TCT. However, a few States found it very useful in trending teamwork and communication and used the data on coaching calls to highlight strategies and tactics to improve these important aspects of safety culture.
Key Success Factors
Senior Management Engagement
Senior management engagement was a key factor for successful States and units alike. State leads cited the importance of enthusiastic hospital association executives who emphasized the importance of the project at the onset and who stayed engaged throughout the project by following participating hospital results and communicating with hospital CEOs to imbue a sense of accountability. All State leads further reported that senior leader engagement was very important to their successful units, and it was their perception that when units lacked this support they were often not able to incorporate CUSP into their daily work as much as other teams. They also suspected that teams without this support were less successful in lowering their CLABSI rates.
Understanding Hospital Team Needs and the Importance of Early Interventions
Many successful States took the time to get to know their teams' strengths and weaknesses and to tailor the tools and interventions based on individual team needs. Examples included taking the CUSP and CLABSI manuals and breaking them down into smaller sections for the teams to assimilate. Other States took the time to walk their teams through the project Web site, which seemed overwhelming to many teams, particularly when they were getting started.
High-performing States found early intervention with units experiencing high or spiking CLABSI rates an effective strategy. These States determined that meeting by phone and/or in-person with these teams was helpful in identifying and resolving barriers. Some State leads used small incentives like inexpensive food gift cards to encourage struggling teams to continue in the project.
Constant Communication with Hospital Units
States that used frequent and multiple forms of communication (group and individual Email, phone calls, and site visits) were more successful in engaging their teams in this work. State leads found the weekly updates from the NPT extremely helpful and used them as the basis for their own weekly updates to their hospital teams.
Celebrating Success
Teams generated enthusiasm to "get to zero" by keeping score on the number of days since their last CLABSI. They did this either by displaying banners or posting on bulletin boards the number of days or months since the last CLABSI on the unit. Many States acknowledged those teams that had low rates and had had zero CLABSIs for an extended period of time. Certificates of achievement or small, inexpensive gifts were also a way that some States celebrated successful teams. This created positive competition for other units to improve so that they, too, could be recognized.
Other Unit-level Success Factors
Physician and Nurse Champions
In the view of all State leads, teams that had engaged and supportive physician and nurse champions were better able to adopt CUSP and lower their CLABSI rates. Nurse champions were vital in supporting the nurse manager and carving out release time. Physician champions were critical to empowering nurses to stop physicians when needed and for holding physicians accountable for not following evidence-based practice.
Multi-disciplinary Focus
State leads noted that multi-disciplinary teams were another key success factor. An important component of the CUSP methodology, multi-disciplinary teams made better decisions because of their diversity of perspectives and understood the importance of inter-disciplinary rounding. It was particularly important to shift ownership and knowledge of CLABSI rates from an infection preventionist to the team of clinicians responsible for providing patient care. Knowledge of CLABSI rates and recognition that the team could prevent them was an important cause of the project's success.
Strong State Hospital Association (SHA) Engagement to Increase Unit Accountability
State leads who kept close contact with their unit teams were able to keep those teams more accountable. Monthly review of each unit's data and communication about those results was viewed as an important motivator for team leaders and their teams.
Improvement Opportunities for Future National Collaboratives
The interviews with State leads conducted in spring 2012 elicited insights to assist the NPT in improving future national collaboratives. These are listed below.
Better Communication of Project Requirements, Other State Lead Resources
Several State leads interviewed noted that they did not anticipate the amount of work entailed in this project, specifically, the amount of one-on-one team communication needed. They wished that HRET had communicated this at the time of State recruitment. States expressed appreciation when the AHRQ expansion contract provided funds for them to hire part-time staff on this project.
State leads expressed appreciation for the State Lead Manual, which was not available at the start of the program for the first two cohorts. They also appreciated refinements to the national project Web site, which could have been easier to navigate in the early stages of the project. State leads initially viewed the five weekly immersion or on-boarding calls as redundant to material presented at the first kick-off meeting. However, as they became more experienced in the project, the high-performing State leads understood that CUSP was the foundation for unit safety work, whether to eliminate CLABSI or to address any other safety issue. The State leads asked that the NPT think about how to better sequence the introduction of the CUSP tools, which appeared overwhelming to their teams in the early phase of program implementation.
Although the NPT attempted to train State leads by providing sample monthly coaching call agendas and by modeling coaching techniques, State leads reported that specific training on how to coach teams would have been helpful. State leads felt unprepared to instruct their teams on how to use the HSOPS results to improve safety culture. In addition, some State leads realized that their unit teams were not taking full advantage of the project Web site and spent dedicated time to walk their teams through it and to show them where and how they could access CUSP and CLABSI elimination resources and archived content calls.
Sustainment
Sustaining the gains in each participating State/region will depend on three major factors: 1) people equipped to function independently as leaders of efforts to reduce HAIs and other unit-based quality improvement (QI) initiatives, 2) an adequate infrastructure to lead these QI efforts in the State/region, and 3) having the knowledge and materials to support ongoing efforts to train hospital personnel in unit-based QI approaches that can be used to reduce infections and to address other safety and quality challenges faced by their unit's patients.
Equipping People
The NPT has promoted sustainment in each State and region by training State association leads and other association staff in the CUSP model and methodology alongside their hospital units. Each month State leads were exposed to coaching techniques by the Armstrong Institute and MHA Keystone faculty advisors assigned to their State/region, and then weaned off the MHA Keystone advisors at month 9, and the Armstrong Institute advisors at month 18. After this point State leads led the coaching calls on their own.
In July 2012 the NPT held a day-long, interactive National Collaborative Meeting for State leads and other State/regional association staff. The purpose of the meeting was to prepare State leads to sustain this work in their State or region. The agenda focused on the skills needed to manage a successful State or regional collaborative and included sessions on sustainability planning, coaching principles, coaching struggling teams, interactive didactic teaching, and teaching via Webinars. All participants received a manual on how to run State/region-based QI collaboratives. The conference was led by faculty and facilitators from AHRQ, the Armstrong Institute, Cynosure Health, HRET, MHA Keystone, and Northwestern's Feinberg School of Medicine. Approximately 60 percent of the States and regions participated in the meeting: 27 States and Puerto Rico. Program materials have been distributed to all participating States and regions. HRET hosted three follow-up coaching calls to further address different aspects of sustainment.
HRET has strongly encouraged each State and region to develop a sustainability plan. Eighteen States, the District of Columbia, and Puerto Rico have indicated their intent to submit sustainability plans to HRET. These plans will address how States and regions will: 1) continue to promote CLABSI reduction by leveraging their experience and knowledge gained in the project and through stakeholder consortia, 2) spread the CUSP model and spread CLABSI prevention to non-ICUs, 3) regularly monitor CLABSI rate data, and 4) continue to coach unit teams and/or leverage other patient safety networks and experts to facilitate peer learning and networking.
QI Infrastructure
The NPT has emphasized the importance of States and regions having adequate numbers of staff trained in QI and patient safety, preferably individuals with a clinical background, in addition to project management skills. For the past several months the NPT has encouraged States and regions to prepare for the project's end by monitoring CLABSI data captured in NHSN or in State-specific databases. HRET is currently asking States and regions if they require extended use of the MHA Keystone Care Counts database to monitor CLABSI rates while they create their own State or regional database if none currently exists.
Knowledge and Tools
Materials on CUSP and technical and clinical interventions to prevent CLABSI reside on the project Web site and will be transitioned to the AHRQ Web site soon after the contract ends in September 2012. A key sustainability resource is the CUSP Toolkit, which will be released after the AHRQ annual conference in September 2012. The Toolkit was designed for State leads and hospital unit staff to successfully design and implement a CUSP-based initiative. It demonstrates how CUSP works with existing patient safety frameworks such as TeamSTEPPS®, Just Culture, and Sensemaking. The CUSP Toolkit is comprised of slide sets, facilitator notes, exercises, and videos. The videos include scripted vignettes, informational presentations, and interviews with CUSP teams. The toolkit was piloted among State leads to obtain feedback on clarity of content and ease of use.
