Running head: LEADERSHIP STRATEGY ANALYSIS

Leadership Strategy Analysis: Quality Improvement Process to Prevent CLABSI Tamara Putney Ferris State University

LEADERSHIP STRATEGY ANALYSIS Abstract Preventing central line associated blood stream infections (CLABSI) in hospitalized patients is

critical to promoting safe, quality patient outcomes. One way organizations can promote optimal outcomes is by utilizing both a quality improvement process and a leadership strategy. By proactively identifying needed changes in the system and successfully engaging staff to accept the change and adhere to evidence based practice for patient care, errors can be averted. CLABSIs are an identified clinical occurrence that is most often preventable. By integrating theory and research based best evidence practice, preventing this type of hospital acquired infection can promote fiscal savings and optimal patient outcomes. Literature proves that strict adherence to evidenced based practice and nursing care standards reduce these infections. In an effort to reduce CLABIs and promote optimal outcomes, an interdisciplinary team gathered and collected data to assess the current state condition of a critical care unit. Data analysis identified the need for implementation of nursing education and a central line insertion checklist as interventions beneficial to prevent these hospital acquired infections. Evaluation of the implemented interventions will take place over time and the expected outcomes are a reduction in the occurrence of CLABSIs and an increase in nursing knowledge in the areas of insertion, use, maintenance, and documentation of central lines. Keywords: hospital acquired infection, CLABSI, quality improvement

LEADERSHIP STRATEGY ANALYSIS Leadership Strategy Analysis: Quality Improvement Process to Prevent CLABSI Ensuring quality and safety in healthcare organizations is critical to promoting an environment that delivers the best patient care (Yoder-Wise, 2011). For organizations, the success in the business of healthcare is very dependent on monetary reimbursements from payers, such as the Centers for Medicare and Medicaid Services (CMS), and from obtaining successful credentialing from agencies such as The Joint Commission (Yoder-Wise, 2011). In addition, reimbursement and credentialing is now dependent on delivery of safe, quality patient

care while producing optimal outcomes. Instituting a methodical quality improvement process is a way health care organizations can identify areas of care producing less than optimal outcomes and design new processes or plans to ensure the care delivered is the best and safest possible. Quality improvement (QI) refers to the ongoing process of innovation, prevention of error, and staff development (Yoder-Wise, 2011, p. 390). The process involves the identification of a need in clinical practice, assembling the proper team to provide input related to the need, collecting the data to justify the need for change, establishment of outcomes desired with the change, implementing the change, and evaluating the change (Yoder-Wise, 2011). Yoder-Wise (2011) explains, Leaders, managers and followers must be committed to QI (p. 392). A strategy for leaders is the use to promote change in a healthcare environment is the Leadership Rounding Tool, developed by the Studer Group (Yoder-Wise, 2011). This is a great strategy because it is built on the premise that better performing and engaged staff produce better patient outcomes (Aiken, Clark, Sloane, Lake & Cheney, 2008). The Leadership Rounding Tool offers an avenue and guidelines to involve staff in the change process (Yoder-Wise, 2011). This tool encourages leaders to build a rapport with staff to retrieve information on what is or is not working well for them and allows for recognition of front line leaders, while providing strategies

LEADERSHIP STRATEGY ANALYSIS to provoke the staff to ask questions they would not necessarily feel they could ask to management (Yoder-Wise, 2011). It must be understood that communication, active listening,

and constant evaluation by management and leaders is absolutely critical to producing successful change. This paper will examine the application of this leadership strategy and the quality improvement process to produce change in the healthcare environment to promote a decrease in the occurrence of hospital-acquired infection from central lines. Clinical Need The prevention of hospital-acquired infection is imperative to ensuring quality outcomes, and delivery of the safest possible patient care. Preventing central line associated blood stream infections (CLABSI) requires many interventions and due to the variability of the healthcare environment can prove to be challenging. CLABSIs are very expensive. Recent Centers for Disease Control (CDC) estimates put each occurrence of a blood stream infection, caused by a central line, at an average cost of about $16,550 per patient (The Joint Commission, 2012). In the United States alone, in all hospitals, CLABSIs occur at a rate of about 250,000 per year and can prolong hospital stays by up to three weeks on average (The Joint Commission, 2012). The occurrence of this type of hospital acquired infection is rapidly gaining attention as the development and implementation of mandates and regulatory requirements for prevention are underway (Agency for Healthcare Research and Quality, 2011). Most states voluntarily report to a national database if a CLABSI occurs (Clark, 2012). But recent legislation set forth by CMS provides an incentive to report by providing a 2% monetary Medicare or Medicaid reimbursement award (Clark, 2012). Currently, since the induction of that incentive, about 300 hospitals report this hospital-acquired infection but, not too far in to the future, pay for performance efforts connected to the Affordable Care Act, will likely require strict mandatory

LEADERSHIP STRATEGY ANALYSIS reporting and impose federal monetary reimbursement reductions if CLABSIs occur (The Joint Commission, 2012; Clark, 2012). There are twenty nine states required by law to report any hospital acquired infections (HAI) to the CDC controlled National Hospital Safety Network [NHSN] (Centers for Disease Control [CDC], 2012).

Up to 70% of CLABSIs can be prevented by strict adherence to evidence based practices when caring for central lines (Umscheid et al., 2011). United States research shows overall poor compliance by nursing staff with adhering to evidence based practices, use of central line insertion guideline bundles, daily assessment for the continued need for the line, site assessment, line maintenance, and documentation (Hatler, Hebden, Kaler, & Zack, 2010). Many research studies have concluded that implementing an education plan for nursing staff will greatly decrease the occurrence of CLABSIs (The Joint Commission, 2012). In addition, ensuring appropriate documentation and justifying the need for the line will promote accurate organizational self-reporting which would equal incentive monies from the federal government (Clark, 2012). Although CLABSIs can occur in any hospital unit, critically ill patients are most vulnerable and tend to have worse outcomes compared to general surgical or medical patients (Hatler et al., 2010). To decrease the incidence of CLABSIs, in the critical care unit, and promote the ease and accuracy of organizational self-reporting (via accurate documentation) in the future, an intense education plan to promote compliance with evidence based practice associated with the use and maintenance of central lines, will be implemented. The plan will stress the importance of prevention of CLABSIs, as well as the consequences of infection, and be designed to promote evidence based nursing care standards.

LEADERSHIP STRATEGY ANALYSIS Interdisciplinary Team Yoder-Wise (2011) explains that when the scope of the project is decided on, an

interdisciplinary team must be assembled. It is important to have a variety of valid opinions and perspectives on what the actual problem is, and what is causing the problem (Yoder-Wise, 2011). It is also critical to have appropriate team members to brainstorm and generate solutions to the problems identified (Yoder-Wise, 2011). This team will consist of anyone that may be involved with the care of the patient, or those to serve as subject matter experts. The formation of the quality improvement team should represent a cross section of workers somehow connected to the problem (Yoder-Wise, 2011, p. 395). For this project one critical care bedside nurse and one charge nurse from day shift and night shift will be recruited. Bedside nurses are the front line users and can contribute valuable knowledge pertaining to real time processes, barriers, and offer effective ideas for optimization of the process. These direct care nurses can also be champions for support during implementation. Charge nurses can give perspectives related to staffing issues, help with implementation and data collection, and act as change agents to support the need for the change. The critical care manager and staff educator will be included to analyze the feasibility of implementation of the plan and help with design; the educator will also assist with the staff education materials. A member from the infection prevention team and the intravenous therapy team must be included to provide expertise on regulations, industry standards of care, and best practice evidence. Other important members of the interdisciplinary team are the quality improvement specialist and a clinical informaticist. These two team members will provide the process step knowledge, create the flow charts, provide expertise with the electronic documentation system, as well as guide and facilitate the steps the team will need to take for project success (Yoder-Wise, 2011). In addition, to give this formal project authoritative support,

LEADERSHIP STRATEGY ANALYSIS an administrator will be asked to indirectly champion the cause. For this project, the chief nursing officer will be recruited. Administrative or high level leadership support promotes the success of large quality improvement projects (Yoder-Wise, 2011). A physician champion will also be important to include because consultation for insertion technique and input on medicine best practice will be needed. Data Collection Data collection is an important process in any change project because it is used to measure the current status of the activity, service, or procedure under review (Yoder-Wise, 2011, p. 396). Data collection will begin with a count of current CLABSI cases over the last year in the critical care unit, as well as the total number of line days for all critical care patients. A bar graph will be utilized to illustrate these baseline metrics. Bar graphs are useful for easily showing frequency of events (Yoder-Wise, 2011). Next, the management team will shadow or

observe nurses on each shift to assess techniques used in insertion, routine use, maintenance, and documentation of information for patients with central lines. The information, observations and comments gathered during shadowing will be used by the team to guide brainstorming sessions and vetting of possible solutions. This baseline data collection will take place over the course of several weeks. It will be important to assess the practices of more than one nurse on more than one shift. Engaging and observing staff in this manner will allow the leadership team to utilize the strategies laid out as indicated by the Leadership Rounding Tool. Shadowing staff provides valuable insight to problems nurses may experience with workflow, technology, or supplies. Random documentation audits will also be completed prior to the start of the projects as a baseline metric. Last, a mandatory, anonymous electronic pretest of baseline knowledge will be

LEADERSHIP STRATEGY ANALYSIS administered to all nurses in the critical care unit to assess knowledge of current evidence based practices related to central line insertion, use, maintenance and documentation. After the data is collected from shadowing, audits and baseline knowledge testing, staff and the interdisciplinary team will convene to design current state flow charts of the insertion, use, maintenance, and documentation process. Flowcharts are helpful in step by step processes; getting real life processes on paper will allow for analysis of gaps or non-value added process that can be optimized (Yoder-Wise, 2011). Established Outcomes Goals for process improvement can be established in a number of ways but always involves a standard of practice and a measurable patient-care outcome or nursing sensitive outcome (Yoder-Wise, 2011, p. 399). After collection and analysis of data, one of the main barriers identified involving the prevention of CLABSIs included lack of consistent, best practice knowledge on use and maintenance of central lines. Relevant literature supports increasing the nurses knowledge of current evidence based practice and demonstrates that this measure has shown to decrease the occurrences of CLABSIs in acute care hospitals (Marschall et al., 2008). The data also demonstrates incomplete and inconsistent awareness of proper documentation and compliance with line insertion best practices, based on research evidence,

while assisting providers with central line placement. Based on this information, the established outcomes of this project will be to: decrease the number of critical care unit CLABSIs by 75% within 6 months, to increase nursing knowledge (by 50% from baseline) in use, maintenance and documentation of central lines, and increase compliance with central line insertion best practices at the bedside to 100% within 6 months. After project implementation, the data will be collected periodically and compared to the outcomes of other hospitals. The process of comparing

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outcomes and measures resulting from care delivery is referred to as benchmarking (Yoder-Wise, 2011). Benchmarking is very important in the quality improvement process and is instrumental in the evaluation of a care delivery and outcomes. Implementation Strategies After brainstorming, identification of gaps, and consolidation of all team member ideas, as well as utilization of strategies from the Leadership Rounding tool to engage staff, a plan evolves to implement the newly designed process (Yoder-Wise, 2011). In order to decrease the number of CLABSIs in the critical care unit an education module will be designed. This education module will be mandatory for all direct care nurses in the unit and will deliver knowledge of current evidence based practices related to central line insertion, use, maintenance and documentation. The beginning of the module will briefly describe the background and relevance of HAIs and the role the CDC, NHSN, CMS and The Joint Commission play with regard to financial reimbursement and quality outcome regulations. The education will be delivered electronically so scores and compliance can be tracked, and nurses will have 30 days to complete the education module. Working with the physician champion, a paper insertion checklist and policy will be implemented for use with every critical care unit central line insertion. Nursing staff will use gentle reminders to medical staff not complying with evidence based practice. All completed checklists will be turned in to the unit manager for evaluation. Nursing staff will understand how to utilize the checklist from information received in the education module. The support structure to answer questions, after implementation of this new process, will consist of members of the interdisciplinary team. This support team will be formally available for one week post implementation. These identified strategies of education

LEADERSHIP STRATEGY ANALYSIS and implementation of an insertion checklist are national, evidence and research based, proven interventions, and recommended by the NHSN (Marschall et al., 2008). By proper utilization of the Leadership Rounding Tool, as well as strategies borrowed

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from the Kotter change model, staff will embrace and promote this quality improvement measure and successful outcomes will be realized. As outlined in the Kotter change model, eight steps have been or will be followed during this quality improvement process to promote the change. The execution of Kotters eight steps: creating urgency, forming a powerful coalition, creating a vision for change, communicating the vision, removing obstacles, creating short term wins, and building and anchoring the change are the responsibility of everyone on the interdisciplinary team (Value Based Management, 2012). Evaluation Evaluation is imperative to any implemented process change (Yoder-Wise, 2011). After implementation of the process improvement interventions, data collection and outcome monitoring will begin. Continual evaluation and monitoring is very important. If it is realized that outcomes are not as expected or problems are identified the process must be reexamined and revised (Yoder-Wise, 2011). An ongoing tally of CLABSI cases and line days in the critical care unit will be documented and placed in a bar graph quarterly to illustrate any change from baseline metrics. Thirty days after implementation a post knowledge test will be administered to all nursing staff and results will be compared to baseline scores. Monthly chart audits for compliance with documentation, use and maintenance of central lines will also be collected and compared to evaluate effectiveness of interventions. Last, working with physicians, utilization and compliance of the insertion checklist will be tracked and analyzed. All team members,

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especially frontline staff, charge nurses, educators and the manager of the critical care unit, must commit to this process change and continually promote the improved practice (Yoder-Wise, 2011). The continuous quality improvement theory helps understand that it is the actual entire work process that defines a process improvement project, not just what is delivered at the end of the line (World Health Organization, 2012, p 165). Conclusion Promoting safe, quality, patient care outcomes is critical. By participating in process improvement, utilizing resources, theories, and evidence, nurses can meet and exceed many provisions as set forth by the American Nurse Association [ANA] thus, promoting the profession and elevating the industry standard. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development (American Nurses Association, 2011, provision 7). All nurses must understand the effectiveness and potential of positive quality improvement initiatives. As Yoder-Wise (2011) explains, as far as quality management is concerned, anything measured and recorded can be improved, (p. 408) as is the case with this quality improvement project to prevent CLABSI. Being proactive instead of reactive in the health care environment and working as a team to fix problems before they occur can be extremely effective if done in an evidenced based methodical fashion (Yoder-Wise, 2011).

LEADERSHIP STRATEGY ANALYSIS References Aiken, L., Clarke, S., Sloane, D., Lake, E., & Cheney, T. (2008). Effects of hospital care

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environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), 223-229. Agency for Healthcare Research and Quality [AHRQ]. (2011). Eliminating CLABSI a national patient safety imperative: A progress report on the national on the CUSP stop BSI project. Retrieved from http://www.ahrq.gov/qual/onthecusprpt/onthecusp.pdf American Nurses Association [ANA]. (2011). Code of ethics for nurses with interpretive statements. Retrieved from http://ana.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurse s/Code-of-Ethics.aspx Centers for Disease Control [CDC]. Facilities in these states are required by law to report HAI data to NHSN. Retrieved from http://www.cdc.gov/hai/stateplans/required-to-report-haiNHSN.html Clark, C. (2012). CMS reveals central line infection rates, finally. Retrieved from http://www.healthleadersmedia.com/page-5/QUA-276383/CMS-Reveals-Central-LineInfection-Rates-Finally Hatler, C., Hebden, M., Kaler, W., & Zack, J. (2010). Walk the walk to reduce catheter-related bloodstream infections: Using evidence based practices, nurses can help prevent deadly infections linked to central venous catheters. American Nurse Today, 5(1), 26-31. Marshcall, J., Mermel, L., Classen, D., Arias, K., Podgorny, K., Andersen, D., Yokoe, D. (2008). Strategies to prevent central line associated bloodstream infections in acute care hospitals. Infection Control and Hospital Epidemiology, 29(S1), S22-S30.

LEADERSHIP STRATEGY ANALYSIS The Joint Commission. (2012). Preventing central lineassociated bloodstream infections: A global challenge, a global perspective. Retrieved from www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf

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Umscheid C., Mitchell M., Doshi J., Agarwal R., Williams K., & Brennan, P. (2011). Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection Control and Hospital Epidemiology, 32(2), 101114. Value Based Management. (2012). Kotter change phases. Retrieved from http://www.valuebasedmanagement.net/methods_kotter_change.html World Health Organization. (2009). Topic 7: Introduction to quality improvement methods. Retrieved from http://www.who.int/patientsafety/education/curriculum/who_mc_topic7.pdf Yoder-Wise, P. (2011). Leading and managing in nursing. (5th Ed.). St. Louis, MO: Elsevier