Case Studies

This private hospital has a designated team, known as the Vascular Access Specialist Team, comprising about 10 registered nurses who have a minimum of two years of nursing experience and are specially trained in central line insertion techniques, ultrasound guidance, and Centers for Disease Control and Preventioninfection prevention guidelines.  â€” View Case Study

This report synthesizes lessons from four hospitals that reported they did not experience any central line-associated bloodstream infections in their intensive care units in 2009. Lessons include: the importance of following evidencebased protocols to prevent infection; the need for dedicated teams to oversee all central line insertions; the value of participation in statewide, national, or regional CLABSI collaboratives or initiatives; and the necessity for close monitoring of infection rates, giving feedback to staff, and applying internal and external goals. The report also presents ways these hospitals are spreading prevention techniques to non-ICU units, and strategies for preventing other health care-associated infections.  â€” View Case Study

This nonprofit teaching hospital relies on intensivists to provide ICU caare. As part of their efforts to improve care, the intensivists recommended use of an evidence-based CLABSI prevention protocol that includes the use of a checklist to promote compliance. To ensure the protocol was followed, the hospital trained and empowered nurses to enforce standards during the placement process and restricted the number and type of hospital personnel permitted to insert lines.  â€” View Case Study

Johns Hopkins Medicine—an academic medical center and nonprofit integrated health care delivery system—set a goal in 2002 of making its care the safest in the world. The Comprehensive Unit-Based Safety Program, which trains frontline teams to identify and mitigate patient safety hazards, is a key strategy. The model has been spread to hospitals nationwide and was associated with reductions in central line–associated bloodstream infections in intensive care units. Through its safety efforts, Hopkins has achieved improvements in safety practices such as increased hand-washing, in patient outcomes such as fewer pressure ulcers among patients, and in the hospital staff’s perceptions of the organizational safety culture. Safety principles have been spread outside the hospital setting to the system’s home care group. Success factors include setting ambitious goals, empowering frontline staff to make improvements, involving executives and the board in change, and rigorously measuring and holding units accountable for results.  â€” View Case Study

Four case studies--of the Department of Veterans Affairs, Sentara Healthcare, OSF HealthCare, and Johns Hopkins Medicine--document the progress achieved in the past five years by health care organizations that were early leaders in patient safety improvement. Their experience reflects an expansion of interventions from individual hospital units to whole facilities and delivery systems, including new settings such as home health care. Approaches include developing practical methods for training, coaching, and motivating staff to engage in patient safety work; designing effective tools and systems to minimize error and maximize learning; and leading change by setting ambitious goals, measuring and holding units accountable for performance, and sharing stories to convey values. Results include advancements in safety practices, reductions in serious events of patient harm, improved organizational safety climate and morale, and declines in malpractice claims. Keeping the commitment to patient safety has required sustained focus on making safety a core organizational value, a willingness to innovate and adapt, and perseverance in pursuing goals.  â€” View Case Study

OSF HealthCare, an integrated health care delivery system serving parts of Illinois and Michigan, was an early leader in promoting a collaborative approach to patient safety improvement. OSF has enhanced these efforts during the past five years by continuing to build awareness of safety risks through systemwide error reporting and local risk assessment, by identifying clinicians who can serve as models for their peers, and by engaging staff in intraorganizational learning and competition to spur improvement. It also has raised performance expectations by educating hospital- and system-level board members about patient safety issues and quality improvement techniques. Exemplary facility-level results include: an 80 percent reduction over six years in the rate of ventilator-associated pneumonia among intensive care patients; an increase from 39 percent to 100 percent in compliance with a standardized medication administration process; and a nine-percentage-point increase over one year in surgical patients receiving evidence-based treatment to prevent infections.  â€” View Case Study

At this nonprofit community hospital, nurses are assigned responsibility for monitoring adherence to the CLABSI prevention protocol, but all staff are encouraged to stop the central line insertion procedure if a lapse in protocol occurs. Per hospital procedure, staff also review daily whether continued use of a central line is necessary.  â€” View Case Study

Sentara Healthcare, an integrated health care delivery system serving parts of Virginia and North Carolina, has developed a systematic program to foster a culture of safety throughout its member hospitals, with the aim of reducing the potential for patient harm. During the past five years, Sentara has intensified and expanded the program by engaging the health system’s physician group and other operating units in efforts to: 1) encourage employees to be mindful of the signals of inadequate care and act on those signals; 2) provide leaders with concrete methods of reinforcing employee behaviors that enhance patient safety; 3) reinforce bulwarks against medical error by instituting processes for learning from mistakes; and 4) reward the attainment of high standards of performance. The initiative has helped to reduce the measured rate of serious safety events at Sentara hospitals by 80 percent over seven years.  â€” View Case Study

This private hospital found that engaging frontline staff was more effective than top-down directives for adopting and maintaining new practices. Also, the hospital relies on a small number of critical care intensivists to conduct or oversee central line insertions, including those performed by residents.  â€” View Case Study

As part of a systemwide transformation, the VA formed its National Center for Patient Safety to foster an organizational culture of safety within its nationwide network of hospitals and outpatient clinics. A recent medical team training program designed to improve communication among operating room staff was associated with a reduction in surgical mortality and improvements in quality of care, on-time surgery starts, and staff morale. The program is now being expanded to other clinical units, along with a patient engagement program that prevents errors by facilitating communication relating to patients' daily care plans. A recognition program stimulated facilities to conduct timelier and higher-quality root-cause analyses of reported safety events to identify stronger actions for preventing their recurrence. Other initiatives have reduced rates of health care–associated infections, patient mortality, and post-operative complications. Success factors include leadership accountability for performance and organizational support for testing, expanding, and adopting improvements.  â€” View Case Study