One example includes recent initiatives to reduce central line associated blood stream infections (CLBSIs), described Russell N. Olmsted, MPH, CIC, 2011 president of the Association for Professionals in Infection Control & Epidemiology (APIC). "Use of a collaborative as a foundation for organizing and engaging direct care providers in preventing HAIs is one of the keys. Of note, CDC’s report in a recent MMWR under their Vital Signs series documented the notable success seen across the U.S. over the past several years. This has often involved use of a collaborative model in ICUs. The other key element is using a culture of safety assessment to survey personnel on the safety and quality of care being provided in their affiliated inpatient unit. Dr. Peter Pronovost and his colleagues have found a Comprehensive Unit-based Safety Program (CUSP) is an essential foundation to assess perceptions and then work to improve the culture of safety by enhancing efficacy of teamwork in the unit where this is deployed."

The CUSP methodology was applied to an initiative to reduce CLBSIs, funded by a grant from the AHRQ and the Health Research and Education Trust (HRET) of the American Hospital Association, that was recently expanded on a nationwide basis. "The basic premise is in the first word of CUSP – comprehensive," explained John Combes, M.D., senior vice president, American Hospital Association, principal investigator for the CUSP project.

Designed as a process improvement tool beyond simply providing technical information about clinical practices, "this program also looks at the behaviors, the culture, the communication skills, the teamwork approach of the bedside clinicians. It’s really not just looking at a checklist or a summary of the current evidence and telling people, ‘go ahead and do it’, it’s really working with them about how to do it, how to perform as a team and hold each other mutually accountable for the work. And I think it’s this comprehensive approach that has made the program so successful. There’s a lot of talk out there about all people have to do is follow a checklist. Well, it’s not quite that easy. You actually have to get them to engage around what it is the checklist is asking them to do and have them incorporate it into their daily work and have it become the way they work. And when it doesn’t happen that way, hold each other accountable for it."

According to Combes, the initial CUSP –CLBSI intervention has truly been successful. "The numbers are getting quite low all across the board for all hospitals, we’re getting down below 1 per 1,000 with a median rate of around 0. The reason for their success, he said, "a lot of it has to come from the leadership of the organizations. Even though this is a project that occurs at the bedside it needs a lot of leadership support from the top of the organization to look at this as a priority in transforming the culture of the workforce. The lesson learned is without strong leadership nothing will happen with this and that’s a key part of it."

"One of the key things early on in this that came out of the work at [Johns] Hopkins and the Keystone Project in Michigan was the creation of the insertion trays where you had all the equipment, all the supplies, in one place including full gowning material, masks, catheters and the chlorhexidine," added Combes. "It’s really about making sure that supplies are organized in a way that’s supportive of the technical intervention that you want to do. "

Combes noted that the CUSP program is being applied to initiatives to reduce other types of HAIs including catheter associated urinary tract infections (CAUTIs), as well as for the reduction of blood stream infections in dialysis units. "Part of the bigger project is to leave the state teams that we’ve formed in each of the 50 states with the CUSP toolkit at the end so they can use it in future interventions including surgical wound infections and other things as well. The CUSP methodology itself is separate from the technical intervention but can make the technical interventions much more successful, so we really want to have at the end of this project a collaborative that are well trained in the use of CUSP so that they can apply it to other interventions."

"For any kind of quality activity, any kind of change in the way we work in our organizations we have to look at both the technical aspects and what we call the adaptive aspects of it," Combes summarized. "It’s as important to have the science behind the intervention as well as to have the appropriate work and the behaviors of forming the culture to be successful and have that success sustained."

VHA Inc. recently announced the results of a regional initiative focused on reducing the incidence of Methicillin-resistant Staphylococcus aureus (MRSA) infections. In late 2007, VHA hospitals in the Central Atlantic region established an aggressive goal to reduce the incidence of MRSA infections within three years. By working with VHA, the 54 hospitals in the initiative reduced their collective MRSA infection rate by 44% by the end of 2010 and prevented $35.4 million in additional treatment costs over the course of the initiative. 

"The key to success was the engagement of the VHA Central Atlantic Board of Directors, typically system/hospital CEO or their designee," shared Terri Bowersox, BSIE, MBA, FACHE, director, performance improvement for the VHA Central Atlantic Region. "The Board decided to work on the MRSA initiative together and set the goal to reduce hospital-acquired MRSA infection in aggregate by 80% in 3 years. Then they provided the vision and support to their organization to make sure they were successful and barriers were taken down. At each VHA Central Atlantic Board meeting, a status update was provided and there was a healthy discussion about how they (the CEOs) can influence this work. We gave the CEOs frequent homework assignments to make sure they were doing what they needed to do as leaders to help their organization be successful in reducing hospital-acquired MRSA infections." 

"All of the hospitals that reduced by more than 70% had great organizational support for the initiative, including the executive team, and also focused a great deal on the basics of hand hygiene compliance, isolation policies and personal protective equipment compliance, and environmental/equipment cleaning," Bowersox added. "Hand hygiene compliance is a basic tenet that will help with all HAIs. During the initiative, those hospitals that put a significant focus on hand hygiene compliance, including use of peer coaches to reinforce the expected behavior, had fewer HAIs." 

Adherence to environmental cleaning protocols was equally important. "We very much encouraged hospitals to monitor compliance on appropriate environmental and equipment cleaning similar to how they were already doing hand hygiene compliance," she said. "For equipment cleaning, it’s important for each staff member to know what their role is in equipment cleaning. At most hospitals, there are a variety of staff doing equipment cleaning, so many hospitals took the time to figure who should clean what equipment and when, to make sure there was role definition. Some equipment goes from room to room, so whenever that happens, it should be the responsibility of the staff member moving the equipment to clean it before entering a new patient room. When we started the initiative, many hospitals had not focused much on cleaning and by doing so, they were able to see reductions in the MRSA infection rate." 

MRSA screening was also a key part of the VHA initiative, with patients being tested upon admission and placed into contact precautions if they test positive for MRSA.