So, now that we've had all this success how do we sustain our intervention. Remember we don't want to have to revisit CLABSI reduction. And actually we don't want to have to revisit any of the quality improvement and initiatives that we've had to work on. Some are mandated by state federal Joint Commission. I mean really when we do this work we want to make sure that we're doing it for the long term. And we'll have opportunities to improve but we don't want it to be so significant that we're coming back all the time. If you look at our implementation framework, about how we implement, we have those questions for the frontline staff, the team leaders and senior executives. So, we've engaged we've educated we've executed and we've evaluated and we've seen that we have a success. We have a success that we don't want to fall back on to say yes we did it, we did it once but we haven't maintained. So, to this framework, we added two more ease and they are embed and expand. And really what we are looking to do is embed this practice.Well and how we go about that I think is just as important as how we do the initial quality improvement initiative. And then is there any place that we've missed. Can we expand this quality improvement initiative to either another unit in our facility or to another organization or to an organization that is owned by one of our organizations because we really don't feel that you should compete on say patients safety. When you come to the hospital patients safety should be a priority for everybody. So, as we look at this we are going to look at some of the practices that we have done to embed. Why do we worry about the distant future?. Well I think if you've been in healthcare or any organization for a long time you realize that there are a lot of things that can happen and we can anticipate that we are going to have turnover from our excellent staff, We are going to be down some bodies at any given time. We are going to see that somebody is going to try to change a policy. In fact right after this work I got calls from a couple of different nurses at different hospitals. They had a new HGIC provider who wanted to not use the surveillance definition. So, their two years of work plus they wanted to go back to looking at each culture separately and not doing surveillance monitoring of patients. So, it meant a phone call and it meant that look at all the work we've done look at where you started and you really want to do that. So, we want to get everybody back on board and we want to make sure that everything is written into policy and everything is set so that there's no opportunity to slide backwards at all. We want to take what we've learned to new projects, to new opportunities that we have for other patients. But when we do that we also want to make sure that we're not losing our ability to maintain what we've already accomplished sometimes over time people become complacent. We think that automatically people will just maintain one of the sad things that I have to report is that I can look and see when somebody has not followed a policy procedure because it ends up in an adverse event file that I'm going to end up reading. So, complacency is a problem. Sometimes people get lazy. Sometimes people are overworked. Sometimes people really wonder does that really matter all that much so one of the things that we did in order to address complacency was we audit behaviors of the providers. So, not only do we audit "did you put the line in right", but we audit the nurses and the techs who are doing the dressing changes. Was it done when it was supposed to be done?. And what's the compliance like. And there have been times when I have done fidelity assessments where I am looking at fidelity to the model and I have seen as much as 40 percent non-compliance within an organization with the guidelines that we have left in place and some of it is lack of knowledge; we found some providers that did not realize what actually having a dressing that was at hearing truly meant. So, there were some opportunities where we found the dressings not adherent where they said oh no they're adherent. So, education; we also found people that years later they still were not using the maximal barrier precaution in the correct way. There are other things that come up any emergencies and complex cases where somebody is always going to have an argument to say that I don't need to do this. Well, you know what, we've addressed that already. We've said that if you've done something within 24 hours and you cannot guarantee that you've placed that line correctly that that line needs to come out within those 24 hours. And they need to be put in the correct way. So, it really is all about maintaining the momentum that you have and keeping the results that you have. Now things you do to support the long term viability of the BSI reduction I think are many. First we write it into policy. One of the things that we looked at were policy and procedures within organizations. And as I said in the beginning we wanted to be pretty black and white. We do not want areas of grey. We don't want to subject to interpretation. In fact if you have a couple of people read it which I think is a great test and they come back and they tell you this means this, this means this, this means this, and you have people that disagree is not written firmly enough sit with them talk with them. What would meet the criteria so that it was black and white so that people would know this is what I do every time all the time. Include the training for all new members. And remember I said when you are looking at your kust team,a nurse educator was great but we also give the science of safety lecture to all of our new residents on the very first day that they start. And we let them know we want them to have the lenses to see patients safety issues and adverse events right away. We also as I said we audit our care to make sure that we are compliant with the evidence based practice and we address issues when we see. We do something more significant now quite a peer to peer assessment where teams from the Armstrong institute step in. We talk to the frontline providers. We actually observe people doing dressing changes placing central lines and we look to see where there are areas that we can improve. So, never ever forget that there's always an opportunity for improvement and that sometimes those people that are new to the organization haven't had the training even though you've set things in motion to really keep them there. The other thing that I think is important is that reliable supply chains you don't want to order or call down to your central stores and find out general have core hexing or you don't have maximal bare precautions if you're in an organization you're in a small organization. I should say see if there's somebody local that would allow you to share. But also these are things that you need to keep stock of to make sure that there's no opportunity for a chance to go back and you want to make sure that somebody is on top of this all the time. And if somebody finds a problem early on, let's just say that there's a national shortage begin to address it. Talk to the people that you've met and that you've networked with over time. Is everybody on your unit feel part of the CUSP team? I think that's a big issue. So initially, we say it's for front-line providers but one of the things that I found when we first got started was people would appoint like the director of respiratory therapy but not include any of the front-line respiratory therapist. Or the nurses would say, "I'm invited but I don't really know whether I have time to go because I have to leave my patient." So, just like you've set up alternatives and coverage for lunch and whatever. Make sure that you set up a buddy system so that some of your front-line people can actually attend your CUSP meetings said they have a say in what goes on in their unit. They are a windfall of information about how your unit works and they really need to be heard. If you find that you've got the wrong mix, you need to look to see if there's somebody else that needs to attend. So, one of the things that we learned early on was, in our own unit, our point of care pharmacists would attend occasionally but not all the time. So, we would go without some of our stock drugs that were missing our Pyxis would be filled incorrectly, significant medication errors did occur. So that gradually we got them to show up all the time to participate. But look at your team to see if you could use a different perspective. We've invited human factors engineers when looking at injuries for staff with back injuries and using some of the equipment getting our patients out of bed. There are always an opportunity to include somebody else and we have guest speakers sometimes to talk about what's the latest in fall reduction or de-cubidist reduction. Always remember that there's always somebody else that you can add to your team. Is there ownership of the CUSP team on your unit? And I think this is important, we ask that not only you have a physician champion and a nurse champion and your senior executive show up but we also ask that we want everybody to consider themselves, if they're there when a meeting is happening, that they are there to be a problem solver. This is another way that we build capacity. Everybody has an opportunity to say what's on their mind and make sure that they're addressing their concerns. I think it's really important that when we talk about embedding this practice, we also plan for the inevitable. What happens when somebody gets promoted? What happens when somebody transfers out? So that we have dual leadership. So, maybe your nursing champion is co-champion with the nurse educator so that if something happened and somebody goes out because of sick leave, maternity or they're promoted, it's not going to leave the team in a lurch. They're not going to be stuck with all this work to do and nobody that really knows the mechanisms of the CUSP team and how that they work together. Finally, and I would say that this is very familiar to a lot of you. Set up your network of peers and other people that can aid you in your work. And for us, it's been hospital epidemiology, the ID nurse comes and reports out everything that we need to know. Building our infrastructure I think locally. And that's how we've done that is with those experts in some of the areas that we're working in and as I said, co-lead because you really want a line of succession so that you say if I'm going to be transferring out of here, who is going to take my position? So, get people that have been active in your CUSP team that take a positive role in fixing what's wrong with where they work and ask them to take on a leadership role. Ask them to lead different projects on their own. Ask them to report out and really give them the sense that the work that they're doing is important and they are really building capacity. And what we've seen over time, is that as we build this capacity, some of our front-line staff have left the clinical area to be patient safety officers within our organization. And I think that as an employer you're always happy when your staff does well. But it also shown that you have really helped this person grow to become an advocate for their patient and for all their patients because they're working in patient safety and quality. And then practices that aided I think our success in Michigan, there are a couple. One is continuous feedback and we had a pretty significant feedback loop. So, the data was given to the Michigan Hospital Association and we got copies of it and looked at the data so they could in real time call the unit and say what was wrong, "Can you please check your data?" I think it's very important. As I said in many other talks and I'll say it in this talk too, this isn't just quality improvement, this is done just as rigorously as any research study because the data is real. We use the real data and the data makes a difference so without the data, you can't show that you've really done anything. So, this isn't quality improvement for quality improvement sake, we want results. There is a baseline and then there is the data at least in monthly or quarterly increments and then your final data. We really want to see what's gone on, very important to the team. So, improvement of safety culture that occurred as part of the overall Keystone ICU project was pretty remarkable 66 percent in two year. Our organizational psychologists would say, "Culture change does not happen quickly." But I think if you have the right group of people working on this and they really see how it benefits the workplace that they're in and also how it benefits their patients. I think that that really began to change. So, people that didn't speak well, didn't work well together, that really began to change and that made a significant difference. The other thing I think was that, getting people to understand and prove to them that you can prevent bloodstream infections. There were many physicians that said, "I've been practicing for so many years I'm happy with the rate of 10 per 1,000." Until they saw that, guess what? You don't have to have any of those. And so many of the teams and as I said, several years later, we published a paper that showed our sustainment was actually there. We were still no higher than we were when we finished the project. And then in my project and in the Adventist project because the organization took such an active role in making sure that club C was done away with. Two years after we finished the Adventist project, their data was the same. So, they had actually maintained, so very important. Involvement of your senior leaders to look at your infection control data and provide the resources that were needed. There were a lot of calls that went on between our director and some of the CEO's that we worked with to provide and make sure that the front-line staff had everything that they need. I think open communications and when you can show that a small thing can do a lot of good for your patient population, it really does make all the difference in the world. And then lastly, a shared goal rather than a conception to reduce and that was that we all knew that this was possible. And to show that it happened throughout a state, was pretty amazing it was the first time that it happened. It was like our new polio campaign. We were going to eradicate central line associated bloodstream infections and we were able to do that.
