Senior Leader Checklist

AHRQ Safety Program for Long-Term Care: HAIs/CAUTI

Purpose: To provide senior leaders a checklist to plan and implement quality improvement and resident safety projects in a long-term care facility.

Who should use this tool? Senior leaders (long-term care facility administrator, director of nursing, medical director, etc.)

How should you use this tool? Highlighted text can be edited with facility-specific project names and goals.

Task Responsible Party Notes
  Assign a senior executive (administrator or another leader) to serve as an active member of the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI team to meet with the facility team(s) at least monthly.    
  Ensure all employees receive education concerning the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI.    
  Make CAUTI reduction a facility wide priority goal. Include this goal in the facility’s strategic plan.    
  Collaborate with staff, residents, and family members to develop a coordinated plan to achieve the goal of CAUTI reduction throughout the long-term care facility.    
  Work with the facility team to determine what project success will look like, plan for hardwiring the process into facility culture, and plan for sustainability.    
  Create a process for facility-level accountability by monitoring and ensuring team progress on agreed-upon project activities.    
  Require that the appropriate office (e.g., Infection Prevention) produce a weekly report of harm. Ensure there is a clear threshold within the data, which indicates areas of concern that require immediate action. The leader should investigate, communicate, and lead action planning on these concerns.     
  Foster organizational learning by disseminating “learn from defect” lessons.    
  Recognize project needs and provide administrative time and resources to support staff participation. Provide time for team leaders (doctor, nurse, certified nursing assistant, data collector, etc.) to complete duties.    
  Acknowledge the teams’ work and celebrate success. Post stories in the facility newsletter and provide opportunities for teams to share success stories with management and other teams.    
  Monitor progress toward the goal no less than quarterly and report performance to all employees and the board.    
  Make executive rounds an organization-level standard of practice.    
Page last reviewed March 2017
Page originally created March 2017
Internet Citation: Senior Leader Checklist. Content last reviewed March 2017. Agency for Healthcare Research and Quality, Rockville, MD.