Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term Care
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
How To Use This Guide
LTC Safety Toolkit Modules
A Culture of Safety
Engaging Partners in Care
Resident and Family Engagement
Data to Drive Improvement
Effective Communication and Teamwork
Assess What's Working
Maintain Staff Competency
Appendix A. Sustainability Assessment Tool and Action Plan
The purpose of this guide and the appended tools and links to resources is to provide long-term care (LTC) facilities with an approach to sustain improvements made through implementation of the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI—reducing catheter-associated urinary tract infections (CAUTIs) and other healthcare-associated infections (HAIs). Through the adaptation of evidence-based practices including the Comprehensive Unit-Based Safety Program (CUSP), tools and resources were developed to eliminate HAIs/CAUTI and enhance safety practices in the LTC setting. This guide provides information, tools, and resources, to support LTC facilities in sustaining practices implemented to reduce CAUTIs and other HAIs, and to improve the resident safety culture.
This program was funded by the Agency for Healthcare Research and Quality (AHRQ), and was part of the U.S. Department of Health & Human Services (HHS) National Action Plan to Prevent Healthcare-Associated Infections.1
Planning for sustainability should happen early in the process of implementing any improvement project. This how-to guide is organized into short sections on critical factors to successfully improve and sustain changes in health care organizations, and lessons learned from LTC facilities that participated in the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI. It provides recommendations, tools, and resources to ensure that the success factors for improving and sustaining an HAIs/CAUTI reduction program are maintained.
The CUSP model was adapted for this program to help LTC facilities improve resident safety, clinical outcomes, and safety culture. The Comprehensive LTC Safety Toolkit Modules (LTC Safety Toolkit Modules) are designed specifically to help leaders and staff apply CUSP principles in the LTC environment. The LTC Safety Toolkit Modules emphasize the importance of a diverse team, focuses on the input of frontline staff, discusses the importance of a common goal, identifies issues that the team can successfully solve, and integrates these elements as part of the team’s routine work.
The toolkit includes training tools to make care safer by improving the foundation of how physicians, nurses, and other frontline staff work together. It builds the capacity to address safety issues by combining clinical best practices and the science of safety.
Improvement strategies can only be sustained if the strategies are embedded into the culture and norms of a facility, so the best time to begin thinking about sustaining program gains is at the beginning of your program implementation. Consider what processes can be integrated into the normal workflow. The LTC Safety Toolkit Modules Sustainability module provides information on essential elements to sustain a quality improvement program and spread it to other areas of your LTC facility or affiliated organization.
Sustainability in health care occurs when a new safety innovation loses its separate identity as a project and becomes embedded into daily work flow, and the improvements in resident outcomes attributed to the new safety practices are maintained or improved after the initial implementation project ends. Sustainability is also evident when LTC staff and providers share their expertise and provide ongoing support to others in carrying out changes.
Too often, well-meaning staff and clinical teams undertake patient safety projects, achieve improvements, and then fail to maintain those improvements over time. Key factors contributing to the failure of HAI reduction efforts over time include not educating new staff in the technical and adaptive aspects of the interventions, failing to require continual competency checks, not incorporating the changes into daily work flow, and ceasing to routinely monitor progress toward achieving or maintaining safety goals.2
LTC facilities may have a variety of reasons to implement quality improvement programs. Transparency of care has increased to consumers of health care as well as to other health care organizations over time. The Centers for Medicare & Medicaid Services is now enforcing how LTC facilities establish and maintain quality assurance and performance improvement processes in an effort to sustain quality care and improve resident safety for nursing home residents.3
More importantly, research has identified six critical success factors for successfully improving health care in organizations that are important to consider as an LTC facility initiates the planning process:4,5
- Strong leadership—at all levels.
- Supportive culture and infrastructure to support improvement.
- Physician involvement and accountability.
- Frontline staff involvement and accountability.
- Use of data to measure performance and drive improvement.
- Effective communication strategies.
A key component to implementing and sustaining interventions that improve resident safety is leadership that is committed to reducing HAIs and improving safety culture. Module 2: Senior Leadership Engagement in the LTC Safety Toolkit Modules provides tools and resources that further explain the role and responsibilities of senior leaders in addressing an LTC facility’s safety goals.
The root of improvement lies in the safety culture within a facility. Leadership and staff perceptions of resident harms such as CAUTIs or falls, and staff harm such as a punitive response to errors, can influence culture. To sustain the gains and continue to make improvements to safety culture, the AHRQ Nursing Home Survey on Patient Safety Culture can help assess staff perceptions of resident safety culture. Consider reassessing safety culture on a regular basis, but not more frequently than every 6 months, to track changes over time. For more information and resources to promote the survey, review Nursing Home Survey on Patient Safety Culture Survey Administration Materials and Results Discussion Guide.
Improving resident safety by reducing CAUTIs and other HAIs and improving the culture of safety are team efforts. Leaders, clinicians, frontline staff, and residents and families should be included in the process in order to sustain the improvements made.
Module 3: Staff Empowerment in the LTC Safety Toolkit Modules provides tools and resources that describe how to empower staff and engage them as part of the team to improve and sustain the safety culture in an LTC facility. It also provides strategies to address and overcome challenges to empowering staff.
Long-term care facilities are most successful when influential individuals, including leadership, are integrated into the implementation and sustainability team. Influencers, or informal leaders, are respected members of the staff that should be highly encouraged to continue to engage other staff to integrate evidence-based practices and strategies that the LTC facility identified as contributors to successfully reducing CAUTI and other HAIs into care. These champions include a physician, nurse, and nursing assistant.
All staff in an LTC facility should also understand why practices are in place to improve the quality of care in the LTC facility. Each individual’s knowledge, skills, experience, and perspective help inform the process and ability to sustain improvements. For example, when an LTC facility is seeking to improve hand hygiene practices, the team is critical to achieving results that can be sustained over time. Furthermore, allowing staff to provide input to allow for some customization that is controlled and tied to the improvements engages existing and new staff in buying into the process.
When goals are reached or maintained over a period of time, celebrations and LTC facility leadership's recognition of the efforts made by all staff can help sustain the gains made to improve resident safety culture and outcomes to reduce CAUTIs and other HAIs.
Improving resident safety and reducing HAIs requires a team effort and should include the resident and family as part of the safety improvement team. Module 5: Resident and Family Engagement in the LTC Safety Toolkit Modules explains why it is important to engage residents and families and their role as partners in facilities’ safety teams, and provides a resident and family engagement checklist. Additional tools and resources to engage residents and families in the program to reduce CAUTIs and other HAIs can be found in the Implementation Guide and on the Consumer Voice Web site.
Establishing a sustainability measurement plan is a key step in determining whether improvements are actually being sustained. Moreover, it can provide data transparency throughout the facility and opportunities to troubleshoot if any issues arise or the team is behind target on goals. Consider which measures you want to focus on as part of the sustainability plan by assessing what will help you sustain capacity. For more information on how to develop a sustainability measurement plan, review the Assess What’s Working section of this guide.
Engaging not only leadership, but nursing staff, frontline staff, and residents and families in monitoring progress also promotes team accountability and integrates the changes into daily workflow. Assess and share program data to encourage, inspire, and motivate the facility staff, residents, and family members. Reinforce the positive changes being made or identify where more or different interventions are needed to optimize safe care for residents who require an indwelling urinary catheter.
To enhance communication skills, AHRQ’s TeamSTEPPS Long-Term Care version provides strategies and tools to engage leadership, staff, and residents and families in communicating and sharing strategies to reduce barriers to safe, quality care. Module 4: Teamwork and Communication of the LTC Safety Toolkit Modules provides evidence on why teamwork and communication enhance resident safety, lists barriers, and offers solutions to overcome barriers to effective teamwork and communication.
Evaluating team engagement and communication with one another, residents, and families is an ongoing process. Continue to meet regularly during existing safety or quality committee meetings to discuss team successes and barriers and to review data trends. Assess what is currently working by reviewing cases of resident safety issues (e.g., CAUTI) each month to find causes and solutions.
Once the program is underway, it is recommended that the LTC facility team understand what program elements and other factors may influence sustainability by completing the Sustainability Assessment Tool. It may be helpful for the team to provide feedback on their experience with the project, which can be used to assess implementation of the project and the capacity to sustain improvements. Results from completing this tool can be used to develop a sustainability action plan to maintain, as well as build, your team’s capacity for sustainability.
Evidence-based clinical practices and cultural interventions implemented during the project can be reinforced through education for both current and new staff. The educational bundles provided on the AHRQ Web site are designed to help the LTC facility educator train facility staff, and when appropriate, residents and families, on infection prevention and safety culture topics. These educational materials can be customized and adapted to your facility’s needs. When developing a sustainability plan, consider one or more of the following approaches to reinforce learning and embed practices into the daily workflow:
- In-Service Education. Use the educational bundles as part of monthly in-service training. Consider engaging the staff by assigning a section to each person and having them teach their peers. The educator can be present to clarify points or answer questions.
- Self-Guided Learning.
- If you have a learning management system (LMS), the educational bundles can be added to your LMS and either assigned to staff (if mandatory) or made available to staff (if elective).
- If you do not have an LMS, the slide sets and notes can be printed and placed in a binder with the supplemental materials. Staff can review the contents of the binder and then complete any accompanying activities that can be graded—either by the educator or individual staff person.
- New Employee Orientation. The educational bundles can be used to supplement your infection prevention orientation curriculum. Consider customizing the education with your facility policies, procedures, and documentation forms.
- Skills Updates or Competency Testing. Use the educational bundles as part of competency testing of staff. Competency testing can be done in a controlled environment, such as a skills lab, or can be accomplished in the work environment using peer observation.
- HHS National Action Plan to Prevent Healthcare-Associated Infections: Road Map to Elimination. Web-based guide. April 2013. U.S. Department of Health & Human Services.
- Sustainability. Toolkit for Reducing CAUTI in Hospitals. Rockville, MD: Agency for Healthcare Research and Quality. Accessed on September 5, 2016.
- QAPI Description and Background. Nursing Home Quality Assurance & Performance Improvement. Centers for Medicare and Medicaid Services; April 2014. Accessed April 11, 2016.
- Barron WM, Krsek C, Weber D, et al. Critical success factors for performance improvement programs. Jt Comm J Qual Patient Saf. 2005 Apr;31(4):220-6. PMID: 159131129.
- McAlearney AS. Final Report. High-Performance Work Practices in CLABSI Prevention Interventions: Executive Summary. (Prepared under Contract No. #HHSA2902010000221, Task Order No. 5.) AHRQ Publication No. 15-0044-EF. Rockville, MD: Agency for Healthcare Research and Quality; May 2015.
Appendix A. Sustainability Assessment Tool and Action Plan
Prepared by Health Research & Educational Trust with contract funding provided by the Agency for Healthcare Research and Quality through Contract No. HHSA 290201000025I.
Disclaimer: The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or HHS.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this document.
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Page originally created March 2017