Hospital looks at itself, culture to fight MDROs
Florida Hospital starts changes at unit level
As part of its journey to prevent health care-associated infections, Florida Hospital's clinical excellence team asked staff what risks they saw. The answers they got were sometimes unexpected, but they helped the team understand the organization's culture and determine which fundamentals should be saved and which should be altered.
This year, Lee Adler, DO, vice president, quality, safety innovation, and research at Florida Hospital in Orlando, was assigned with strategic oversight for the eight-hospital system's rollout to fight multidrug-resistant infections (MDROs). He began the journey by asking a lot of questions on the front lines, getting input from multiple disciplines and piloting projects on a unit level.
Assessing where it was
With more than 120,000 patient admissions, 1 million patient contacts, and more than 360,000 ED visits in a year, Florida Hospital, "is a big outfit," Adler says.
"Organizations have various attitudes to [addressing MDROs]. Since Florida Hospital is so complex, we needed to ask ourselves, 'What do we have to do to change the fundamentals within the organization, and what are the nice-to-haves once the fundamentals are in place?'"
To answer this, they first performed a risk assessment. In the formal risk assessment, Adler collaborated with Christine Kaptur, RN, BS, MA, CIC, LHRM, administrative director, office of clinical excellence, which includes an infection preventionist and project manager. They chose to separate out the emergency department and the acute care inpatient departments. "The ED is a complex, pressure-filled environment," Adler says. Many patients coming in are an unknown risk, already immune-compromised or harboring bacteria with common complaints including abdominal pain, diarrhea, fever, cough or many are coming from nursing homes or long-term care facilities.
"We knew we needed a different mindset than that from the inpatient side, where the patient has somewhat been screened either by a physician upon entry into the hospital or by the ED," he says.
Adler also assembled interdisciplinary health care workers from the front lines of patient care at the system level and each of the eight hospital campuses to identify differences in terms of risk. The evaluation team was trained to look at risk first in terms of highest-perceived risk from staff and consumers. That highlighted critical quality issues, including hand hygiene, environmental cleanliness, contact precautions, and education. With education, he found, it wasn't necessarily related to the education of doctors and nurses, but of other staff — transport, environmental services, nutrition, respiratory therapy, pharmacy, and others who "go in and out of rooms."
Adler's team asked staff: What are the pebbles in your shoes? What are the things that you believe are not safe? What would you change? What do you see as the issues? One conclusion he found was "the way nurses felt about the physicians in the hierarchal sense was the same way the environmental service worker felt about nursing." Building a team-based environment is a critical success factor, Adler says. Staff "help each other all the time, but they don't necessarily communicate effectively."
Using spread to get change
Adler chose to use the spread improvement plan from the Institute for Healthcare Improvement (IHI) to tackle MDROs. Using the model, you begin a pilot and then spread it using early-adopter units and personnel. These early adopters are the ones who "really want to make a difference," Adler says. From there, you move to include two or three other units and "eventually when you get your 10 to 20 units, depending on how big your organization is, you can probably get a standard work process and then spread it from there much more quickly."
Most of the units have what Adler calls nurse practice counsels. He told them and the unit's nurse managers he wanted them to do these three things:
- convene a triad including the unit medical director, the unit nurse manager, and the infection preventionist (who acts as an expert resource);
- "really believe," as a unit, that "this is important and have enough volume of infections or transmission of infection on that unit to establish a baseline data and track and trend change following implementation of any changes"
- be willing to communicate and share with other units the challenges it faces and how it created solutions.
Cleanliness, cleanliness, cleanliness
In talking with staff, the team discovered that the roles in cleaning a room for discharge varied from nurse to nurse and unit to unit. In addition to patients being discharged, there was a different environmental service cleaning standard for isolation and non-isolation patients.
Systemwide implementation of hand hygiene protocols also was being led by Kaptur on a unit basis. Adler, who has published studies on the topic, says it's critical to understand that education, policy, and testing knowledge are each insufficient on their own. To become effective, one must focus on both behavioral and ergonomic issues. "It's more than just having enough sinks, enough soap, and everything else; it also comes down to ownership and holding each other mutually responsible, offering mutual support, establishing mutual respect, and it's all unit based among core team members," he says.
Compliance, he says, often varies from one unit to another. "I believe our bone marrow units are 95% or better. You don't walk onto their floor unless you're going to wash your hands and practice appropriate isolation procedures because that's the culture of expectation to which you're held. You may go to a routine medical-surgical unit and find a totally different microculture and patient medical conditions. And you may find a much lower percentage of hand hygiene," he says.
To gauge actual compliance, units collected baseline measurements. Did the units have adequate dispensers? Were they positioned correctly? Was the foam in the dispensers and were adequate levels available? After determining their compliance, the units came to a consensus on their own about how to keep the dispensers filled and how to coordinate with environmental services.
Adler says compliance audits were done. Sometimes nurse managers would turn in a compliance order reporting 92% compliance, but a "secret shopper"-type audit would reveal that compliance actually was 30-40%. "Many of our campuses' unit nurse managers agreed to assign different frontline nurses to rotate the responsibility for doing the observations. The nurses who were assigned were unknown by their colleagues," Adler says.
"We did that for a couple of reasons. One is to get everyone to own and believe the validity of their data. There is a place for external audits; however, it is counterproductive when outside people collect data, telling you the data are right when you believe they're wrong. If your group is responsible for the data, you're more likely to take responsibility for monitoring and holding each other accountable."
Environmental services must be on team
Adler also asked the nurse managers to convene on a daily basis at a huddle with frontline nurses, environmental service workers, respiratory therapists, and others, if available, such as the unit medical director. This core team could exchange ideas, review performance, and inform the nurse managers regarding issues of isolation, discharge cleans, hand hygiene, and barriers.
The risk analysis showed high risk on the unit level regarding environmental cleaning. So Adler's team took a picture of a dirty discharge room and turned it into a big poster. They had environmental service staff come in and place green tabs on areas they thought should be cleaned; nurses placed red tabs. Their managers could then identify gaps and engage staff in discussions of any issues regarding specific roles on each unit and create a standard work process for system leadership's ultimate approval.
Alert systems, education to be improved
National Patient Safety Goal 7 on health care-associated infections requires that after a risk assessment, facilities must implement an alert system that identifies new patients with MDROs as well as readmitted or transferred MDRO-positive patients.
Adler says the system's MDRO alert system required improvement and increased stakeholder support, and assessing those was definitely a part of the risk assessment they did at the outset. "We had some electronic alerts, but they were not effective or fully deployed or aligned throughout the organization," he says. So a collaborative clinical team including physicians, nurses, and infection preventionists started working with the information systems department to improve them.
Annual education of licensed independent practitioners, also a component of the goal, is new and challenging, he says. Building annual education for physicians, allied health care workers — such as physician assistants and nurse practitioners — the rest of the staff, and new employees is critical and mandatory.
"We're turning toward several methodologies for education, which include computer-based learning programs, [to be done] at their convenience or show at their departmental or campus medical staff meetings. We'll conduct grand rounds that we will video and distribute to the campuses for physicians who are unable to attend. We will offer continuing medical education credits and expect physician participation," he says.
He suggests reviewing and adapting your hospital's medical staff bylaws to obligate physicians and those in allied health to complete these annual programs and require documentation to incorporate into physicians' credentialing files.
Define priorities with risk assessment, metrics
Adler suggests formulating data collection and information flow plans and asking: What processes will you monitor — hand hygiene, contact precautions, etc.? How often will you report them and to whom? Get hospital executives involved. At Florida Hospital, they are piloting executive visits to the units at least once a month in which the executives question staff if they perceive any barriers; the senior leaders also have been charged to do three or four observations of hand hygiene or contact precaution compliance and leave a note for the nurse manager describing their observations — for example, two out of four hand hygiene opportunities were compliant. "Even though we're not expecting executives to keep count, it sends a message of organizational commitment to the frontline nurse manager and their staff, that this is not another flavor of the month," Adler says.
Adler says all the processes that are to be answered on the system level — such as the alert system, prevalence studies, and active surveillance — are or will be piloted on the unit level.
His suggestion for other hospital quality, safety, and risk departments looking at preventing MDROs: "It's very important not to forget to do the baseline and post-intervention measurements. Once you achieve your goals, select key processes to monitor in order to sustain the gains. Post the results in a visible unit location. Scope your projects carefully and get the frontline and nurse management engaged early on to, create a team-based mindset. Engage the assigned unit physician directors to pull in their colleagues. Florida Hospital is still on the journey — MDRO programs require continuous improvement and social networking to achieve patient safety, reduce transmission, and decrease infections."
As part of its journey to prevent health care-associated infections, Florida Hospital's clinical excellence team asked staff what risks they saw. The answers they got were sometimes unexpected, but they helped the team understand the organization's culture and determine which fundamentals should be saved and which should be altered.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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