Carbapenem-Resistant Enterobacteriaceae (CRE) Control and Prevention Toolkit

Section 2. Starting Your Project

The work of redesigning existing clinical practices must start with an assessment of the current state of staff knowledge and practice, so that a plan for change can be developed in response to specific needs in your organization.

In Section 1.5, you identified members of your organization who might be willing to take ownership of this effort. It is recommended that some or all of those people join the implementation team to oversee the prevention effort and help manage the clinical changes.

If you already have experience with using teams to guide practice change efforts, you may be able to skip ahead to Section 3.

In this section, we will consider the following questions:

  • How can you set up the implementation team for success?
    • Who should be on the implementation team?
    • How can you help the implementation team get started?
    • How will the implementation team coordinate with other teams working on infection control in your facility?
  • What needs to change?
    • How do you start the work of redesign?
    • What is the state of staff knowledge about KPC?
    • How does a KPC-specific intervention differ or fit into existing infection control efforts?
  • How should goals and plans for change be developed?
    • What goals should you set?
    • How do you develop plans for change?
  • How do you bring staff into the process?
    • How do you get staff engaged and committed to new KPC infection control guidelines?
    • How can you help staff adopt new practices?

2.1 How Can You Set Up the Implementation Team for Success?

An infrastructure to support clinical process redesign will help your organization adopt new clinical guidelines. The center of this infrastructure tends to be an interdisciplinary implementation team with strong links to hospital leadership, members who have necessary clinical expertise, a clearly defined task, and access to the necessary resources.

Successful teams have strong leaders who help define members' roles and responsibilities and keep the team accountable for achieving its objectives. Senior leadership support is important for successful change, but change must happen from the ground up. Frontline health care workers, including physicians and nurses, must be actively engaged.

This interdisciplinary team will be responsible for initiating the KPC prevention project, making key decisions about project design and working with the units to implement new clinical guidelines and monitor progress. It is essential that it include some members with clinical expertise who can bring that experience to bear in project design.

You will face a number of decisions in setting up the implementation team. Decisions will include—

  • Who should you put on the team?
  • How can you help the team get started on its work?

2.1.1 Who Should You Put on the Implementation Team?

As suggested above, the most effective teams have several characteristics:

  • Interdisciplinary: Infection control nurses, infectious disease specialists, and bedside staff all will be key to bringing practical and clinical knowledge to the process. Use Tool 2A (Multidisciplinary Team) to help identify other possible team members.
  • Strongly linked to leadership: One way to have adequate senior leadership support is to include a senior leader on the team, but this may not always be feasible or appropriate. As an alternative, consider asking senior leadership to designate a champion for KPC prevention, and the team's leader can stay in contact with that person.
  • Linked to Quality Improvement: The implementation team will be strengthened by having a member with expertise in process improvement methodology and team facilitation.
  • Linked to the affected clinical areas: It is not always possible to anticipate all of the areas of your facility that will need to be involved, but it's important to think broadly about the units and departments that might be affected by the initiative.

Go to Tool 2A for suggestions about different staff members and stakeholders to include on your implementation team.

Resources: Visit these Web sites for ideas on selecting implementation team members:

2.1.2 How Can You Help the Implementation Team Get Started?

Changing routine processes and procedures to alter the way in which people conduct their day-to-day work is challenging. Successful implementation teams pay explicit attention to the development of systems that make new clinical practices obvious, easy, reliable, and efficient, but the way they do their work may vary.

The team will need to consider the following questions:

  • How will the team do its work? This question refers to the day-to-day of team operations, what resources are needed and what methods the team will employ to do its work. How will the team assess current knowledge and practices? How will the team use that information to change clinical practices? How often will it meet? How will members communicate with each other?
  • What's the team's agenda? The team needs a clear charge and scope for its work. Can leadership provide team members with a clear understanding of the short- and long-term goals and timeframes for implementation of KPC prevention efforts?

Here are some tips on effective teamwork:

  • Write a clear statement articulating the scope of the implementation team's charge.
  • Ensure that senior leadership agrees with the statement.
  • Communicate with team members about why they have been included and make sure their efforts are recognized.
  • Provide team members a basic orientation to quality improvement principles and approaches.
  • Make sure your team has the information it needs about the scope of the KPC problem at your facility and at nearby health care institutions, and your reasons for doing this work. 
  • Be clear about the expected outcomes of the project.
  • Schedule team meetings at a time and place convenient for team members, and make sure meetings are scheduled frequently enough to make progress.
  • Develop a timeline for specific tasks and outcomes.
  • Assign team members responsibility for those tasks and outcomes.

2.1.3 How Will the Implementation Team Coordinate With Other Teams Working on Infection Control?

In the remainder of this section we will discuss activities that the implementation team will manage. The implementation Team will need to collaborate with people involved in infection control more generally, as well as those working on quality improvement in individual units.

The KPC control project will look at the strengths and deficits in existing infection control efforts and evaluate how new clinical guidelines can fit into existing workflows. The team will determine what changes need to be made, and what specific practices, tools, and materials it needs to accomplish its goals. The implementation team will need to call on infection control or infectious disease specialists and/or unit-based quality improvement teams. Infection control and unit-based quality improvement teams will be responsible for maintaining gains.

The implementation team will need to ensure that all relevant stakeholders are involved, and that the respective roles of both the team and other relevant parties not on the team are clear in order to avoid overlapping and duplicated effort. Each team should be responsible for specific tasks and project outputs, and the breakdown of those tasks should be clear from the start. The implementation team needs to think about not only individual responsibilities of team members, but also ways those responsibilities interact, types of ongoing communication and reporting needed between members, and the best method to link work across organizational units.

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2.2 What Needs To Change?

In this section, we identify the steps the implementation team needs to take to assess the current state of infection control practice. These steps are based on the principles of quality improvement, defined broadly to include system redesign and process improvement.

2.2.1 How Do You Start the Work of Redesign?

Many of the tools the team will need are either provided or referenced in this toolkit. Your organization may already be familiar with this type of quality improvement process. If you are not sure about the strength of your organization's quality improvement infrastructure, you may want to complete the quality Improvement Process Inventory (Tool 2B) found in the Tools and Resources section. If some of the quality improvement processes listed in this inventory are not fully operational or present at all in your organization, you may need to build your team's improvement capability. Improvement efforts tend to be the most successful when teams follow a systematic approach to analysis and implementation; however there are many different approaches.

Here are a few examples of improvement processes:

  • PDSA (Plan, Do, Study, Act)—PDSA assumes that not all information or factors are available at the outset; thus, repeated cycles of change are going to be necessary in order to achieve the goal, each cycle closer than the previous. With the improved knowledge, we may choose to refine or alter the goal (ideal state).
  • Six Sigma—Developed at Motorola, Six Sigma relies on careful analysis of data on deviations from specified levels of quality, and uses redesign to bring about measureable changes in those rates. Six Sigma incorporates a specific infrastructure of personnel with different levels of training in the methodology (e.g., "Champions," "Black Belts," etc.) to take different roles in the process.
  • LEAN/Toyota Production System (TPS)—TPS is an integrated set of practices designed to bring problems to the surface in the context of continuous workflow, level out the workload, develop a culture of stopping to fix problems, promote the use of standardized tasks, enable worker empowerment to identify and fix problems, allow problems to be visible, and ensure the use of reliable technology that serves the process. If your organization already has a well-established quality improvement process, connect your KPC project with those processes.

2.2.2 What Is the Current State of KPC Prevention Activities?

It will be useful to link new KPC guidelines to existing work being done on infection control in your facility, your referral network, and your community. The work of implementing new KPC control guidelines will mean assessing current infection control practices. In addition to the tools discussed below, you may want to look ahead to Section 5 for additional tools assessing screening practices.

Consider the following questions:

  • What aspects of your current KPC prevention procedures follow best practices?
  • What practices diverge in small or major ways?
  • Which gaps are organization-wide? Which are specific to one or more units?
  • What are other facilities in your community already doing to control the spread of KPC?
Understanding the Organizational Context of Infection Control Activities

As a preliminary step, the implementation team will want to review the organizational context for existing screening and monitoring practices on the units:

  • Have your efforts to control healthcare-associated infections in general been effective? If not, what barriers have they encountered? How can you avoid the same problems? If they have been successful, are there lessons they can build on?
  • Does your organization have an infectious disease specialist or infection control nurses, or both? If not, what are your options for building or acquiring that expertise?
  • Are physicians involved in infection control on the units? In what ways? What are their attitudes?
  • How is information about emerging infections documented and shared? What metrics, if any, are used to assess organizational performance on infection control or with respect to regular screening of admitted patients?
  • Is information about emerging infections documented and communicated with referring facilities? Or other facilities in your community?
Understanding the Current Process on the Units

In order to integrate KPC prevention activities into existing infection control procedures, it's important to have a full picture of those practices. In many organizations, there are gaps between best practices and actual work practices; the extent and size of these gaps is usually unknown until current practices are systematically examined. Understanding current practices will help you better target your approach and document progress that is made. Best practices for KPC prevention are outlined in Section 3, and approaches to measuring key processes of care are outlined in Section 5.

Process Mapping To Document Current Practices

You can use process mapping to examine the key processes where infection control activities could/should be happening. Process mapping can be applied to a specific process, such as inpatient admissions to the Emergency Department, to better understand which individuals carry out each step of the process. Pay particular attention to both the movement of the patient and the movement of the information.

Define who will conduct the mapping and exactly what process will be mapped. Clearly define a start point and an end point and a methodology of all of the processes that are mapped. Making these decisions ahead of time will greatly improve the quality of the data you collect.

Integrating Change Into Current Work Routines

Beyond mapping current clinical practices, and identifying gaps between best practices and actual practices, it's important for the team to think about how recommended care guidelines can be integrated into current infection control practices, or general patient care workflow. It is essential that the team examine how new activities relate to other existing efforts, such as those related to  hand hygiene and infection control, in order to ensure that new processes fit logically with existing efforts and do not create unintended consequences. For example, in one hospital, collecting samples from patients was initially assigned to day-shift nurses; however, a later analysis of the unit workflow revealed that it fit better into the patient care activities carried out near the end of the night shift, and responsibility for this process was thus shifted from days to nights. Steps to consider:

  • Conduct an assessment of current practices on a sample of representative units to determine existing infection control practices that can be translated to work on KPC prevention and control.
  • Use process mapping to describe current control and prevention practices and identify potential problem areas. Process mapping will enhance your understanding of how and when infection control fits into existing care processes. Compare assessment results across units to determine which prevention challenges are organizationwide and which may be unit specific.
  • Determine what practices need changing and consider how the new practices can be built into ongoing routines.

Go to Tool 2C, Current Process Analysis for tips on how to carry out a process analysis in order to understand the current state of practice.

2.2.3 What Is the Current State of Staff Knowledge About KPC?

KPC is an emerging infection that some staff members may not know about. Additionally, staff may have varying levels of knowledge about healthcare-associated infections more generally due to staff turnover, prior knowledge, and training. In order to address these gaps through education, you need to know what the gaps are and where they are located.

Based on an analysis of current staff knowledge, you can assess potential barriers to change. For example, do staff members believe infections are inevitable? Do they believe it's too challenging to maintain contact precautions with family members entering and leaving patient rooms? Because not all barriers are evident from the beginning, it's important to continue to be attentive to potential barriers as implementation moves forward. Here are some steps to consider:

  • Administer an inventory of KPC infection knowledge and infection control knowledge more generally to staff members (Tool 1A). 
  • Consider collecting demographic information at the same time so that your results can be analyzed by unit and occupation. Since this is an educational needs assessment, we do not recommend asking staff to include their names unless they want direct feedback on their score, since that may decrease participation. Develop methods to correct knowledge gaps and misunderstandings.

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2.3 How Should Goals and Plans for Change Be Developed?

In the following sections, the toolkit provides guidance on how to develop goals and implementation plans for the changes you have determined are necessary.

2.3.1 What Goals Should You Set?

Once the team has analyzed the data collected, the team will want to review the evidence on best practices and the clinical guidelines found in Section 3. Before turning to these steps, the team will need to set goals for improvement. These may be related to specific outcomes (e.g., a reduction in the incidence rate of KPC in a specific unit, or an increase in successful isolation of colonized patients) and/or to specific processes (e.g., successful screening of all patients admitted through the emergency room). Goals should be related to both current data and broader benchmarks. It will help you identify your next steps.

For example, your analysis may have revealed specific problems related to processes of care:

  • While staff maintain contact precautions when in physical contact with the patient, they do not wear masks or gowns when they enter the room but do not plan to touch the patient.
  • Contact precautions are not maintained if/when patients are transferred to general medicine floors.

If you identify gaps in care processes, you may want to set improvement goals aimed at reducing those gaps. If you identify gaps in staff knowledge, you may want to set improvement goals in that area.  These are key actions to take:

  • Set improvement goals based on outcomes and processes
  • Identify internal and external benchmarks to judge goals and progress
  • Use goals to guide next steps in redesigning infection control practices

2.3.2 How Do You Develop a Plan for Implementation?

By now, the implementation team will be in place, and you will have developed much more information about the current state of infection control in your organization. The current state of quality improvement efforts in your organization should also be clearer, and a specific team of staff members should have been identified to advance KPC control and prevention efforts. It is now time to develop a more specific plan for implementing new practices and assessing the plan through consistent data collection and analysis. This plan should be extended and refined by work to be completed in response to additional questions we explore in Section 4.

While this plan will need to be flexible in order to be responsive to particular unit-based variation, it is critical to formulate a comprehensive plan to guide next steps. The clinical guidelines and best practices discussed in the next sections are critical to the implementation plan, but are not independently sufficient. They must be implemented within the context of many other factors.

Also, it is important to begin thinking early about sustaining the improvements you have put in place (as discussed in Section 6). Thus, the implementation plan should address—

  • Membership and operation of the interdisciplinary implementation team.
  • Clinical practice guidelines to be met.
  • Gaps in staff education/competence to be addressed.
  • Plans for rolling out new standards and practices where needed.
  • Accountability for monitoring implementation.
  • Ways changes in processes and performance will be assessed.
  • Ways the effort be sustained.

The Plan of Action found in Section 7, Tools and Resources, can be a useful template for developing your implementation plan (Tool 2D) .

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2.4 Checklist for Managing Change

This is a good time to make sure the steps taken so far will contribute to a successful launch of your effort. Use this checklist to make sure you've addressed all of the key areas.

Area Completed

Implementation Team composition

 
  • Team leader identified and in place
 
  • Members with necessary expertise/roles identified and invited
 
  • Linkage to senior leadership defined and established
 

Team startup

 
  • Team agenda and charge clearly stated
 
  • Team has necessary training and resources to get started
 

Current state of practice and knowledge

 
  • Current practice and policies systematically examined
 
  • Challenges to good practice identified at organization and unit levels
 
  • Staff knowledge assessed
 

Starting the work of implementation

 
  • Approaches to implementation explored and chosen
 
  • Gap analysis of current practice and guideline-consistent practice completed
 

Setting goals and plans for change

 
  • Specific goals set
 
  • Plan for making changes to meet those goals initiated
 
  • Preliminary plan for sustaining those changes established
 

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Page last reviewed April 2014
Page originally created March 2014
Internet Citation: Section 2. Starting Your Project. 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/cretoolkit2.html