Two More E’s and How to Spread

1. Two More E’s and How to Spread

2. Learning Objectives • To think ahead about ways to make your investment of time and improvements in BSI rates last forever • To make sure all patients in your institution have access to the same level of safety in their care

3. Implementation Framework

4. Implementation Framework

5. Endure—Plan for Sustainability • Why worry about the distant future? • What you can anticipate • Turnover of staff and new staff • New projects and distractions • Complacency • Emergencies and complex cases (someone will call for exceptions to be made)

6. Endure—Plan for Sustainability • Things you can do now to support long-term viability of BSI reduction • Write it into policy • Include in training for all new members • Audit or monitor to be sure it is routine practice • Set up reliable supply chain (borrowing protocol, alert system, assign someone) • Have a quarterly review by executive partner • Set up a learning network of peers • Have regular meetings with your infection preventionist

7. Endure—Plan for Sustainability • Practices that aided sustainability in the Michigan Project • Continued feedback of infection data that the team perceived as valid • Improvements in safety culture that occurred as part of the overall Keystone ICU project • Unremitting belief in the preventability of blood stream infections • Involvement of senior leaders who reviewed infection data and provided teams with needed resources • Shared goal rather than a competition to reduce infection rates throughout the State Pronovost, PJ; Goeschel C., et al. “Sustaining Reductions in Catheter-Related Bloodstream Infections in Michigan Intensive Care Units” British Medical Journal, February 4, 2010; 340:c309.

8. Expand—Spread the Intervention • Why think about expanding to other units? • Requires self study • Solidifies own understanding • Provides equal protection for all patients (lines are placed elsewhere) • May offer new ideas and methods or may change your perceptions of your own implementation when you see other units’ unique challenges

9. Expand—Spread to New Projects • Why think about your next project? • Can always improve quality • Use new capacity to change to make care better • Maintain engagement of staff and interest and attention of management • Permits some control over what the next initiative will be • Offers a more rewarding environment

10. IHI’s A Framework for Spread • Make the project an organizational goal or strategic initiative • Identify an owner or executive responsible for spread • Identify person or team to manage day-to-day spread activity • Bundle changes (or interventions) in an easily adopted and tested package • Develop plan and targets for spread initiative • Define specific goals of spread • Define specific improvements that will be made • Define timeframe of the spread effort • Create template for feedback report to the sites for monitoring progress Massoud MR, Nielsen GA, Nolan K, et al. A Framework for Spread: From Local Improvements to System-Wide Change. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006.

11. Action Items • Start planning now for sustaining the intervention for years to come • Work with your executive partner and unit heads to expand the intervention into other units • Engage staff in thinking about the next mountain they would like to climb while maintaining low BSI rates

12. Reference List • Buchanan D, Fitzgerald L, Ketley D, et al. No going back: A review of the literature on sustaining organizational change. International Journal of Management Reviews 2005; 7(3):189-205. • Evashwick C, Ory M. Organizational characteristics of successful innovative health care programs sustained over time. Fam Community Health. 2003 Jul-Sep;26(3):177-93. • Greenhalgh T, Robert G, Macfarlane F, et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004;82(4):581-629.