Carbapenem-Resistant Enterobacteriaceae (CRE) Control and Prevention Toolkit

Section 1. Assessing Your Readiness for Change

The implementation of new clinical practice guidelines and procedures of any type can be challenging and complex, because efforts to reduce the spread of infection frequently require system-level changes and collaboration across multiple unit and even multiple facilities. However, it is even more difficult when it involves multiple simultaneous modifications to work flow, communication, and decisionmaking as is needed in the control of healthcare-associated infections, such as KPC. Failure to assess your organization's readiness to make changes across multiple levels and in multiple departments can lead to unanticipated difficulties in implementation of new practices.

In this section, you will consider the following questions:

  1. Do organization members understand why new infection control guidelines are needed?
  2. Is there urgency to implement a new KPC prevention strategy?
  3. Is there leadership support?
  4. Who will take ownership of this effort?
  5. What resources will you need?
  6. What if you are not ready?

1.1 Do Organization Members Understand Why New Infection Control Guidelines Are Needed?

Readiness requires both the capability to implement new practices and the motivation to make the necessary changes. While the motivations for change might be external, (e.g., new guidelines or reimbursement policies), you will have the greatest success if the new initiative is based on a clear understanding of the concerns behind the planned change at all levels of the organization.

The emergence of KPC in health care settings is a significant challenge to all health care professionals. These general statistics might help you engage others in your organization:

  • KPC first emerged in North Carolina in 1999. By 2013, it had been documented in 42 States, and has reached endemic levels in 6 States.
  • According to a 2010 study, overall mortality for patients infected with KPC was 23 percent in 7 days, 42 percent in 30 days, and 60 percent by the end of their hospitalization.

Also consider whether local cases might be more tangible or compelling. While those who work in infection control may have a clear understanding of the changes that need to occur, it's important to remember that there may be great variation across the organization in levels of knowledge/motivation around KPC and HAIs in general.

To gather support and identify potential barriers for a KPC prevention and control initiative, consider the following steps:

  • Identify the reasons to start a KPC prevention and control program in your health care organization. If the reasons are general and not specific to your hospital, you may want to find KPC infection cases or examples that will help bring the issue home to your facility. Examples include cases in facilities similar to yours in size or population served, or cases that received negative publicity.
  • Determine your facility leaders' interest in infection control. Assess the effort needed to obtain and sustain their support.
  • Talk with people in various roles, levels, and clinical areas who have a stake in seeing new KPC prevention and control guidelines implemented.
  • Seek their input and develop consensus on reasons this program needs to go forward.
  • Assess the extent to which organization members beyond potential supporters understand why a comprehensive KPC control and prevention initiative is needed.
  • Consider finding a unit where KPC has been identified, where patients might be at the greatest risk of infection, or where staff is particularly interested in implementing the initiative , and find out what staff members in that unit think .

Updating knowledge and changing attitudes requires not only sharing new information but also assessing and addressing knowledge and/or attitudes that may slow down implementation. Consider surveying staff members throughout the organization to assess their current attitudes and knowledge around infection control—it will help target educational efforts and provide a benchmark against which to assess improvement.

Use a survey to assess clinical staff attitudes about and knowledge of KPC. A survey developed at Boston University can be found in Section 7, Tools and Resources (Tool 1A, Clinical Staff Attitudes Toward KPC Control and Prevention). 

Additional Resources

Below are citations of recent articles about the emergence of KPC. These may provide helpful background for you and others who are supportive of new guidelines at your facility.

  • Bratu S, Mooty M, Nichani S, et al. Emergence of KPC-possessing Klebsiella pneumoniae in Brooklyn, New York: epidemiology and recommendations for detection. Antimicrob Agents Chemother 2005 Jul;49(7):3018-20. PMID: 15980389.
  • Gupta N, Limbago BM, Patel JB, et al. Carbapenem-resistant Enterobacteriaceae: epidemiology and prevention. Clin Infect Dis 2011 Jul 1;53(1):60-7. PMID: 21653305.
  • Won SY, Munoz-Price LS, Lolans K, et al. Emergence and rapid regional spread of Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae. Clin Infect Dis 2011 Sep;53(6):532-40. PMID: 21865189.

If senior leaders do not already support a new KPC initiative, you will need to build the case for implementation. The case for implementation may be different for different people in your organization. To get the support of the chief financial officer, you may need to make a business case—how much will KPC infections cost the hospital in terms lower reimbursement rates? For other stakeholders, such as clinical chiefs, you may need to make the case with clinical outcomes and patient care.

A template for developing a business case for KPC control and prevention can be found in Section 7, Tools and Resources (Tool 1D, Business Case Form).

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1.2 Is There Urgency To Implement a New KPC Prevention Strategy?

Beyond understanding the need to change clinical guidelines, do organization members find something compelling about KPC prevention and control? If a sense of urgency does not yet exist among key leaders, your job as a change agent is to create it or increase it.

Consider the current organizational attention to healthcare-associated infections in general:

  • Does the organization have infection control champions on each unit? If not, who has the lead responsibility for infection control on the units?
  • Are HAIs regularly documented, and are the results/reports provided to the staff? Who receives the reports, and who takes action?

The answers to these questions will influence the way you make your case for a specific KPC prevention initiative. To the extent that an existing infection control program is not present, your task will be more difficult, and mounting an effective improvement effort will likely require strong leadership support.

Here are some ways to increase the sense of urgency:

  • Reach out beyond those who are already supportive and begin talking with colleagues about KPC, and about infection control more generally and its importance to your facility.
  • Use their responses to gather information about potential barriers.
  • Conduct a stakeholder analysis to identify key individuals and departments invested in the success of this project.

A template for stakeholder analysis can be found in Section 7, Tools and Resources (Tool 1B, Stakeholder Analysis)

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1.3 Does Leadership Support This Effort?

It is crucial to make sure your organization's leadership team shares the urgency about KPC prevention and is willing and able to provide complete and ongoing support for this effort. Lessons learned from past efforts suggest that support is needed from all levels. Ask these questions about leadership support:

  • How does this effort fit with the values and goals of your organization?
  • Are there other commitments, initiatives or projects around healthcare-associated infections?

Changes are going to require new or reallocated resources, both human and material. In order to assess leadership support and other questions raised here, consider using a facility-level assessment similar to Tool 1C, Leadership Support Assessment. This assessment can help you assess potential support you can enlist for this effort. If you find that many answers are not positive, this information can help you identify areas that need attention.

Other Resources

Saint S, Kowalski CP, Banaszak-Holl J, et al. The importance of leadership in preventing health care-associated infections: results of a multisite qualitative study. Infect Control Hosp Epidemiol 2010 Sep;31(9):901-907. PMID: 20658939.

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1.4 Establishing Ownership

Improvement projects need strong advocates, members of the organization who are committed to the project's goals, will take responsibility for the outcomes, and can influence others to get involved. To be successful, you'll need more than just one or two champions. You will also need support from various disciplines. Given the high prevalence of multidrug–resistant organisms among the chronically ill and long-term–care populations, you may want to consider including medical staff from frequently referring long-term–care facilities.

  • Look carefully at the yes and no answers in Tool 1C, Leadership Support Assessment. If senior leadership support is not adequate, take steps to inform leaders of the importance and potential benefits associated with KPC and infection control more generally. 
  • Answer the following questions: Who are the key leaders? What will get them on board, if they are not already on board? What will keep them on board? Which senior leader can be the sponsor, link, or champion for this effort?
  • Develop the case for KPC prevention targeted to the priority concerns of the key leaders using Tool 1D as examples.
  • Consider:
    • Who cares about this issue?
    • Where would the logical home base be for this effort in your organization?
    • Are there individuals in that part of the organization who might be willing to take ownership of this project?
    • Are there external organizations or facilities that need to be involved?

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1.5 What Resources Will You Need?

In addition to identifying an implementation team, your project will require both material and human resources. It is also important to meet with senior administrators to determine if funding is available, and how much. Consider creating a checklist, such as the Resource Needs Assessment (Tool 1E).

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1.6 What If You Are Not Ready?

You should not move ahead unless you are confident that your organization is ready, based on the results of the tools discussed thus far. You should assess each area of readiness for the implementation of new clinical practice guidelines. To the extent that readiness is not yet evident, or only partial, it is critical to take steps to address those areas. At a minimum, the facility must have one senior leader who understands the importance of this effort and is committed to supporting the effort, both with resources and in terms of any necessary changes to workflow processes.

Ways to build readiness and support may include—

  1. Trying implementation in a single receptive unit to demonstrate success to the rest of your organization.
  2. Holding one-on-one meetings with key official and unofficial leaders to present your case for change and persuade them that improvement efforts will pay off.
  3. Collecting and sharing data on the magnitude of KPC infection rates, either in your facility or in your geographic area.
  4. Identifying and recruiting project allies who can help spread the word.
  5. Conducting a general staff awareness campaign.

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Page last reviewed April 2014
Page originally created March 2014
Internet Citation: Section 1. Assessing Your Readiness for Change. Content last reviewed April 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/cretoolkit/cretoolkit1.html