Sustaining Change

Slide Presentation

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Sustaining Change

Eugene S. Chu, MD, FHM
Director of Hospital Medicine
Boulder Community Health
Associate Clinical Professor of Medicine
University of Colorado School of Medicine

Image: On bottom left of every slide is the CUSP symbol.

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Learning Objectives

  1. Differentiate between implementation and sustainment.
  2. Identify key elements in sustainment of process improvement initiatives.
  3. Recognize the patient care unit’s readiness for sustainment.
  4. Describe the steps to sustainment.

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Acknowledgements

Sarah Krein, PhD, RN
Research Associate Professor
Division of General Medicine
University of Michigan

Mohamad Fakih, MD, MPH
Medical Director
Infection Prevention and Control
St. John Hospital and Medical Center

Images: Photos of Drs. Krein and Fakih.

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Journal Articles on Sustainment

Images: Screen shots from the title and author sections of 2 journal articles.

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Implementation

Image: Chart showing progress from Engaging and Education to implementation of CUSP. Two lines go up and slowly go down.

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Implementation

Image: Chart showing progress with Execute and Evaluate in the middle of chart to implementation of CUSP. Two lines go up and slowly go down.

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Sustainment

Image: Chart showing progress with Sustainment at the end of chart to implementation of CUSP. Two lines go up and slowly go down.

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Implementation

Technical Socio-Adaptive

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Implementation

Technical Socio-Adaptive

Image: On top left side of slide is an image of a brain with three little people around it, with one of them standing on top.

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Implementation

Technical Socio-Adaptive

Image: On top left side of slide is an image of a brain with three little people around it, with one of them standing on top, and to the right is a red heart.

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Implementation

Same slide as slide 10, only there is a picture of a tree in the middle of a field as background to the words Technical Socio-Adaptive.

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Culture

…the shared set of social values and beliefs, both explicit and implicit, that guides actions and decisions within the organization

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Culture

A coherent culture is one in which there is widespread agreement around core values and beliefs.

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“I know it when I see it.”

Potter Stewart 1915-1985

Image: Portrait of Potter Stewart.

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The 4 E’s of Change

Engage
Educate
Environment
Evaluate

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Sustainment

Effectiveness
Institutionalization
Capacity
Context

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Sustaining Change

Engage
Educate
Environment
Evaluate

leads to:

Effectiveness
Institutionalization
Capacity
Context

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Sustaining Change

Same slide as slide 17, only the words Engage and Effectiveness are circled.

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Engage

Vision

Passion

Finances

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Passion

Image: Elderly man in hospital bed getting an IV.

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What is the diagnosis?

  1. HCAP
  2. Meningitis
  3. C. diff
  4. CAUTI

Image: Same elderly man as on slide 20.

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Indication for UC?

  1. Patient comfort
  2. Nurse convenience
  3. Incontinence
  4. No indication

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Passion

Image: Elderly woman with the hand of a health professional on her shoulder.

Image: Small drawing to the right showing a woman with a book opening imagining scenes from a fairy tale.

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What did the staff do with Mrs. B’s urinary catheter?

  1. Change it to an antimicrobial coated catheter.
  2. Leave it in, it’s more convenient for everyone.
  3. Change it out every 3 weeks.
  4. Wait until she fell asleep to take it out.

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Finances


Daily Census ALOS Yearly Admits Foley Rate Annual Savings
800 4 73,000 25% $1.1M
400 4 36,500 25% $552k
200 4 18,250 25% $276k

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Vision

Imaginable
Feasible
Desirable
Focused
Flexible
Communicable

Accomplished

Images: To the right of the text is the image of a stick figure holding a flag on top of a hill. On the left is the cover of the book "Leading Change" by John P. Kotter.

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Sustaining Change

Same slide as slide 17, only the words Educate, Institutionalization, and Capacity are circled.

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Education

FACTS

FLOW

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Facts

HICPAC guidelines
Appropriate
Inappropriate
CAUTI rates, definitions
UC utilization
Cost/CAUTI

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Flow

Skin care
Bladder scanner
Condom cath
Female urinals
Aseptic Insertion Technique
Maintenance Technique
Closed System

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CAUTI definition changes 2015?

  1. Requirement for ≥ 100,000 CFU/ml organisms in urine culture
  2. Exclusion of non-bacteria as sole pathogens
  3. Use of same pathogen list for symptomatic UTI (SUTI) and asymptomatic bacteremic UTI (ABUTI)
  4. All of the above

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Sustaining Change

Same slide as slide 17, only the words Environment, Institutionalization, and Capacity are circled.

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Environment

Structure

People ⇔ Things

Process

Procedures ⇔ Protocols

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Structure: People

Image: Photo of smiling health professionals.

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Structure: Leadership

Keep Effort Priority
Provide Expertise
Liaison with Peers

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Structure: Things

Images: Photos of a hospital commode, a hospital monitor, a catheter tube, and a male urinal.

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Process: Protocols

Image: Screen shot of the flowchart titled Foley Catheter Removal Protocol.

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Process: Procedures

Image: Screen shot of the form titled Device Risk Evaluation Tool.

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Sustaining Change

Same slide as slide 17, only the words Evaluate and Context are circled.

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Context: Internal

Internal Environment: organization geared towards quality and safety. leaders adopting best practices, employee satisfaction and morale

(Krein et al, Soc Sci Med 2010; 71: 1692-1701)

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Context: External

External Environment: public reporting, value based purchasing, hospital acquired condition penalties

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Evaluation

Use data to assess progress:

  • Hospital Survey on Patient Safety
  • Infection rates
  • Process measures
  • Organizational and team culture

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Evaluation: Metrics

Catheter Prevalence
CAUTI Rate

National → State → Hospital → Unit → Provider

Image: Cartoon of a report card with all A+'s.

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Our Metrics Are...

  1. chart reviewed
  2. automated
  3. mixed

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Evaluation: Metrics

Catheter Prevalence
CAUTI Rate

National → State → Hospital → Unit → Provider

Images: Cartoon of a report card with all A+'s and a wrench.

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Don't Forget the Cookies

Image: Photo of a plate of cookies.

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Implementation → Sustainment

Image: Line graph showing 2 bell curves and the first third of the chart is labeled Engage and Educate, the middle third is labeled Execute and Evaluate, and the last third is labeled Sustainment.

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Sustaining Change

Same slide as Slide 17.

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Program Sustainability Conceptual Model

(Shediac-Rizkallah, Health Educ Res 1998; 13: 87-108)

Image: Figure showing a framework for conceptualizing program sustainability. The three components that make-up Program Sustainability include: 1) Factors in the broader community environment 2) Factors within the organizational setting 3) Project design and implementaion factors. Program Sustainability is defined as: 1) Maintenance of health benefits from a program 2) Institutionalization of a program within an organization 3) Capacity building in the recipient community.

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Thank you!

Questions?

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Funding

Prepared by the Health Research & Educational Trust of the American Hospital Association with contract funding provided by the Agency for Healthcare Research and Quality through the contract, “National Implementation of Comprehensive Unit-based Safety Program (CUSP) to Reduce Catheter-Associated Urinary Tract Infection (CAUTI), project number HHSA290201000025I/HHSA29032001T, Task Order #1.”

Return to CAUTI Toolkit Sustainability Page

Page last reviewed December 2017
Page originally created November 2015
Internet Citation: Sustaining Change. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/sustaining-change-slides.html