NUR 8320 Module 5 Leading Quality Change Paper: The Keystone ICU Project, Context Factors and a Collaborative Plan Example

From 2.7 to Zero: Leading a Catheter Infection Collaborative Across Nine ICUs in a Bergen County System

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8320: Organizational and Systems Leadership I

Mentor Name

Month Day, Year

From 2.7 to Zero: Leading a Catheter Infection Collaborative Across Nine ICUs in a Bergen County System

The Variation Problem

The Bergen County system in this paper, four hospitals with nine adult ICUs, does not exist. Their rates of central line-associated bloodstream infection range from near zero in two units to more than three per 1,000 catheter-days in three others, although all use the same policies and supplies. Each infection adds days, costs and risk of death. The DNP-prepared system vice president for nursing quality has been asked to bring every unit to the best performers' level.

The cost of the variation is concrete. Last year the nine ICUs had 46 central line infections. Using the system's own estimate of about $45,000 in added costs per infection, the infections cost roughly $2 million, along with longer stays and some deaths that may have been preventable. Two of the three high-rate units are in the system's smaller hospitals, which have fewer infection prevention staff and less access to data, a fact that shapes the support they receive in the plan.

What a Statewide Collaborative Achieved

Pronovost et al. (2006) reported the Keystone ICU project, a collaborative in which 103 ICUs, mostly in Michigan, put in place an evidence-based package aimed at bloodstream infections from central lines. The package combined a short list of practices at insertion, namely clean hands, full barriers during insertion, chlorhexidine on the skin, avoiding the femoral vein and removing lines once they were no longer needed, with a checklist, a cart with supplies, empowerment of nurses to stop insertions that did not follow the practices and feedback of infection rates. Across 375,757 catheter-days, the median infection rate went from 2.7 for every 1,000 catheter-days before the work began to zero within three months, while the mean dropped to 1.4 from 7.7 by months 16 to 18. The study had no concurrent control group, which the paper notes, but the size and speed of the change across so many units were striking.

Why Some Units Succeed and Others Do Not

Kaplan et al. (2012) asked ten quality improvement experts to review the literature and build a model of the contextual factors that influence improvement success. The Model for Understanding Success in Quality identifies 25 factors at different levels: the external environment, the organization, the microsystem or unit, and the improvement team. Factors within the unit and the team, such as unit leadership, a culture supporting improvement, staff motivation and the team's skills, are thought to shape success directly, while organizational and external factors, such as senior leadership support and payment incentives, act indirectly.

Braithwaite et al. (2017) reviewed 62 studies and found healthier workplace cultures paired, time and again, with better patient results, including fewer infections. Their review supports attention to culture as part of any collaborative.

Diagnosing the Units

Using the context model, the vice president interviews each unit's nurse manager and physician director and reviews data. The two best units have physician and nurse co-leaders who review every infection within a week, nurses who stop insertions when practices are missed and monthly rate feedback posted on the unit. The three worst units lack physician engagement, have high nurse turnover and learn of infections months later from the infection prevention department.

The Leadership Plan

The collaborative applies Keystone's practices and adds leadership actions targeted to context. Each ICU names a nurse and physician co-lead pair, with protected time. Senior leaders, including each hospital president, adopt an ICU, attend its monthly meeting and help remove barriers, a practice that engaged executives in the Keystone work. Every infection is reviewed within a week by the unit team, with the findings shared across all nine units. Nurses are explicitly empowered to stop a non-emergency insertion when a practice is missed, and the chief medical officer states that physicians will support them. Infection rates are posted monthly on every unit and in a system dashboard. The three highest-rate units receive coaching from the leaders of the two best units.

The plan also respects each hospital's history. One of the high-rate hospitals tried a checklist three years ago that faded within months, and staff there are skeptical. The vice president meets with that unit's nurses and physicians first, asks what went wrong last time and builds their answers into the plan: the old checklist was too long, nobody looked at the data and leaders stopped attending. The new effort keeps the checklist to five items, posts rates monthly and commits the hospital president to attend.

Data support follows the same logic. The two smaller hospitals receive help from the system's infection prevention team to calculate monthly rates and to review each infection within a week, so that every unit sees its results as quickly as the best units do.

Sustaining the Gains

Gains often fade after a collaborative ends. The plan builds the practices into insertion order sets and supply carts, makes infection review part of each unit's standard work and keeps the system dashboard permanent. New staff learn the practices in orientation.

Measures

The system will track infection rates per 1,000 catheter-days for each unit, catheter utilization, compliance with the insertion checklist, the number of stopped insertions and how quickly each infection is reviewed. A balancing measure, the rate of other hospital infections, checks that attention to one does not cause neglect of others.

Conclusion

The Keystone project showed that a simple set of practices, a checklist and nurse empowerment, with feedback, could drive catheter infections toward zero across many ICUs. The context model explains why the same practices produce different results in different units, and a review of culture shows why leaders must attend to it. The Bergen County plan pairs the practices with co-leaders, executive sponsors, rapid infection review, explicit nurse empowerment and coaching from the best units, built into standard work so the gains last.

References

Braithwaite, J., Herkes, J., Ludlow, K., Testa, L., & Lamprell, G. (2017). Association between organisational and workplace cultures, and patient outcomes: Systematic review. BMJ Open, 7(11), Article e017708. https://doi.org/10.1136/bmjopen-2017-017708

Kaplan, H. C., Provost, L. P., Froehle, C. M., & Margolis, P. A. (2012). The Model for Understanding Success in Quality (MUSIQ): Building a theory of context in healthcare quality improvement. BMJ Quality & Safety, 21(1), 13-20. https://doi.org/10.1136/bmjqs-2011-000010

Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S., Sexton, B., Hyzy, R., Welsh, R., Roth, G., Bander, J., Kepros, J., & Goeschel, C. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355(26), 2725-2732. https://doi.org/10.1056/NEJMoa061115