Building National Health Care Quality Improvement Campaigns to Succeed: Lessons from the CUSP: CLABSI Project (Text Version)

On September 27, 2010, Stephen Hines made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (715 KB).  

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Slide 1

Building National Health Care Quality Improvement Campaigns to Succeed: Lessons from the CUSP: CLABSI Project

AHRQ Annual Meeting
Sept. 27, 2010

Steve Hines, PhD
Health Research and Educational Trust

Slide 2

Presentation Overview

• CUSP: CLABSI Project Origins and Background.
• The Challenge of Evolving a National Project.
• Implications for Project Design and Planning.
• Final Thoughts.

Slide 3

Project Origins and Background

• In the beginning was the Keystone Project...
• ...and it was very good!

An image of the Michelangelo Sistine Chapel painting and the map of Michigan is shown.

Slide 4

CUSP: CLABSI Project Rationale

• Blood stream infections kill 40,000-60,000 persons each year.
• Reducing the BSI rate from 5 per 1,000 days to 1 per 1,000 days will save 20,000 lives annually.
• Michigan Keystone Project showed that this level of reduced CLABSI rate was achievable and sustainable.
• Project made central part of Secretary Sibelius' Healthcare Acquired Infection Reduction Initiative.

Slide 5

CUSP: CLABSI Project Goals

• Outcome Goals:
  • Reduce BSIs to 1 per 1,000 central line days.
  • Some states and hospitals view CLABSI elimination as the goal.
  • Improve unit safety culture.
• Reach hospitals in all 50 states, the District and Puerto Rico.
• Include both ICUs and other units with CLABSI risks.
• Include critical access hospitals.

Slide 6

CUSP: CLABSI Implementation Content

CUSP

• Educate on the science of safety.
• Identify defects.
• Assign executive to adopt unit.
• Learn from defects.
• Implement teamwork and communication tools.

CLASBI

• Wash hands prior to procedure.
• Use maximal barrier precautions.
• Clean skin with chlorhexidine.
• Avoid femoral lines.
• Remove unnecessary lines.

Slide 7

CUSP CLABSI Intervention Processes

Individual Components

• Planning/ orientation calls.
• Baseline data collection period for CLABSI and safety culture.
• Kickoff meeting.
• Monthly infection rate and team process data submission.
• Monthly content calls.
• Monthly coaching calls.
• Monthly feedback reports on outcome and process measures.
• Mid-course meeting.
• End-of-project meeting.

Project spans two years and requires participation in:

• 2-3 in-person meetings.
• 48-60 calls led by national project team.
• 24 internal meetings of implementation team.
• Monthly data collection, submission, and assessment (lessons learned/root cause analysis).

Slide 8

The Challenge of Evolving a National QI Project

Slide 9

A Tale of Two Airplanes

	Wright Flyer	P-51 Mustang
Design & Build Prototype	4 years	117 days
Production Time	6 months for Flyer II & III	21 minutes at peak
Range	24 miles	1,100+ miles
Speed	39 mph	400+ mph
Altitude	200 feet	30,000+ feet

Images: A Wright Flyer plane and a P-51 Mustang plane are shown.

Slide 10

Obstacles to Evolving

• Proven initial model: Change distances project from proof method will work.
• Project databases: Stability justifies creating and building a robust national database.
• Evaluation: Simpler and cleaner to assess outcome of a single intervention.
• Project planning: Proposal submission process requires plan easier to execute than to modify.
• Budgets/Contracts: Executed agreements with subcontractors commit resources for specific tasks.
• Clarity: Change creates questions and confusion.

Slide 11

Lessons from Two Airplanes

Change is difficult, risky, but absolutely essential for mass production (or a national rollout to succeed).

Images: A Wright Flyer plane and a P-51 Mustang plane are shown.

Slide 12

Predictable Evolutions in National QI Campaigns

1. Key challenge shifts from obtaining proof change is possible to achieving change in specific units.
2. Baseline problem level changes from 5 infections per 1,000 central line days to 2-3 infections per 1,000 central line days.
3. Goal changes from under 1 infection per 1,000 central line days to total elimination.

Slide 13

Predictable Evolutions in National QI Campaigns

4. Participant expectations change from uncertainty of success despite effort to (over)confidence in success with minimal effort.
5. Participants change from innovators and early adopters to mid- to late-majority hospitals.
6. External environment changes from project as unique and innovative to project as one of many improvement activities in the area.

Slide 14

National QI Campaign Paradoxes

• The more successfully a national QI campaign begins, the more pressure there will be for it to remain unchanged and the more need it will have to evolve quickly and substantially.
• Nothing guarantees failure more than continued, unreflective reliance on the processes that first produced success.

Slide 15

Preparing to Successfully Adapt to Change

Factors Evolving	From	To
Challenge Definition	Creating evidence improvement is possible	Practical guidance on achieving improvement
	Proof rates can be lowered	Proof decreases are sustainable
Baseline Defect Rate	Recognition of a significant problem	Erroneous belief the problem is fixed
	3-4 Sigma improvement strategies	5 Sigma improvement strategies

Slide 16

Preparing to Successfully Adapt to Change

Factors Evolving	From	To
Project Goals	Significant reduction	Complete eradication
	Achieving superior performance	Avoiding inferior, substandard care
Participant expectations	Change is doubtful, long, and hard	Change should be fast and simple
	Comprehensive and redundant training	Efficient, streamlined training
	Dependence on project leadership for success	Dependence on internal and local leadership for success

Slide 17

Preparing to Successfully Adapt to Change

Factors Evolving	From	To
Participants	Innovators and early adopters	Mid and late majority and laggards
	Proof from national experts and visionaries	Proof from local and regional leaders
External Environment	Project is unique, exciting, and cutting edge	Project is one route to success among many
	Few implementation activities have occurred	Partial interventions have occurred in many places
	Coordination with alternate projects irrelevant	Coordination with alternate projects essential
	Belief problem is unfixable independently	Belief problem can be fixed without external help

Slide 18

Implications for Leaders of National QI Campaigns and Funding Organizations

• Proposal Evaluation.
• Budgeting.
• Goal Setting.
• Project Leadership.
• Operational Processes.
• Data Bases.
• Evaluation.

Slide 19

Implications for Leaders of National QI Campaigns and Funding Organizations: Key Questions

Project Dimension	From	To
Proposal Writing & Evaluation	Is it a viable, proven plan?	What is the plan for adapting to inevitable change?
Budgeting	Are all resources allocated to good causes?	Are resources fungible and are unallocated resources retained to support needed adjustments?
Goal Setting	What outcome goals are set at the outset?	Are change goals defined and outcome goals adjusted?

Slide 20

 

Implications for Leaders of National QI Campaigns and Funding Organizations: Key Questions

Project Dimension	From	To
Project Leadership	Does project have stable, credible leadership?	Does project have a plan to develop and transition to new, local or regional leaders?
Operational Processes	Are processes well defined and proven?	How will processes become faster and more efficient?
Data bases	Will stable, robust databases be created?	Can databases inexpensively evolve to reflect needed changes?
Evaluation	Were processes followed and outcomes achieved?	Did processes evolve to achieve outcomes more efficiently?

Slide 21

 

Final Thoughts

• Critical to distinguish between essential success factors and processes for helping hospitals implement them.
  • Success factors for CUSP: CLABSI
    • Culture change that makes safety a priority and empowers every employee to hold every other employee accountable for safety.
    • Operational changes that reduce infections.
  • Processes likely to morph: Set of meetings and calls used to educate, motivate, and empower unit staff to implement CUSP: CLABSI.

Slide 22

 

Final Thoughts

• Critical to recognize inherent tensions in national campaigns:
  • Consistency & clarity vs. need to change.
  • Strong national leadership vs. flexible local leadership.
  • Design that supports strong, clean evaluation of impact vs. design that maximizes operational impact.
  • Processes likely to morph: Set of meetings and calls used to educate, motivate, and empower unit staff to implement CUSP: CLABSI.
• More research and reflection required on how to make national campaigns successful and efficient (e.g. Scale Up & Spread Conference funded by AHRQ, Commonwealth Fund & others.

Slide 23

 

Final Thoughts

• Need to account for context in planning and executing a campaign:
  • Inevitable that parts of campaign will not take place in ideal context.
    • Could be ideal when funded, less enthusiasm during implementation.
    • Could be ideal at kickoff, but requires visionary funder that correctly times the trend.
  • Need strategies for both directly influencing participants and for shaping the national environment to support campaign's goals.

Slide 24

 

Questions

• About presentation:
  • Steve Hines
    shines3@aha.org
    312-422-2607
• About participating in CUSP: CAUTI or CUSP:CLABSI
  • dbohr@aha.org
    646-678-4280

Disclaimer: Although the CUSP: CLABSI project is funded by AHRQ and is being led by a partnership that includes Johns Hopkins University and the Michigan Health and Hospital Association, the opinions in this presentation are exclusively those of the presenter. Like an effective national campaign, these views are also likely to evolve over time.