Six Steps Took These Heroes to Zero

Maureen Larkin, senior editor-quality, April 10, 2008

Several weeks ago in this space I asked the question, “Will We Ever See Zero?” The “we” referred to healthcare organizations and the “zero” the rate of patients acquiring infections during their hospital stays. At the time, I was skeptical that we would ever see zero, but shortly after, I was introduced to individuals at three different organizations who do believe zero is possible. Why do they believe this? Because they’ve done it. Their organizations have achieved a rate of zero catheter-related blood stream infections and held it for several months at a time. Over the next three weeks, I’ll introduce you to these organizations and show you how they became “zero heroes.”

At Beth Israel Medical Center in New York City, CEO David Shulkin says many factors led the 1,106-bed system to become “zero heroes.”

“Like every other effort in a hospital, it’s multi-factorial and multi-dimensional. There’s not just one thing you can point to,” Shulkin says. “Several specific things have led to our success.” He names six actions that helped the hospital succeed.

1. Have the right leaders
Shulkin gives a lot of credit to the organization’s director of infection control, Brian Koll. Koll has taken charge and inspired the organization’s staff to really work to prevent infections. “He understands the value of communication, education, and he’s passionate about what he does,” Shulkin says.

2. Train your staff’s ‘natural leaders’
In conjunction with the Service Employees International Union Chapter 1199, Beth Israel trained members of the hospital staff to become infection coaches. These staff members were educated in what it takes to reduce infections—specifically handwashing and the importance of wearing gowns and gloves when inserting central lines. “The union supported us in a joint effort. Now we have a small army of employees who are knowledgeable about controlling infection,” Shulkin says.

3. Show them what they’re missing
Even when you wash your hands, there still could be germs that you’re missing. That’s why Beth Israel uses a product called Glow, a gel that shows germs still left on hands.
“We had our infection control staff go around with the Glow and show people how they really need to wash their hands,” Shulkin says. “Having the visual component of this was very, very important.”

4. Stop when you see red
If an employee—at any level—sees something happening at the hospital that puts a patient at risk, he or she has the responsibility to speak up and stop the process. This “red rule” was put in place by Shulkin almost three years ago when he assumed the CEO position. “We all carry around red rule cards and if we see anyone who is about to put in a central line without doing everything in the bundle (wearing gowns and gloves and washing hands), we’re supposed to stop it. And we take this seriously,” he says. In addition, the infection control staff can issue “tickets” to anyone that deviates from best practices. “They can take out a ticket pad and write someone up and tell them what they’re doing wrong,” he says.

5. Empower the employee
The red rules are just one way that Beth Israel uses to put infection control power in the hands of its employees, Shulkin says. “We want them to feel that they own and are accountable for these results,” he says, “and that every employee has the ability to eliminate infection.”

6. Give feedback
Each unit at Beth Israel has frequent poster presentations of data to allow employees to measure the progress that their infection control methods are making. The presentations not only help instill ownership of the data among employees, but Shulkin says they’ve also inspired a bit of competition among units.

Perhaps the most important message that Shulkin offers his fellow hospital leaders is to be patient and consistent with your message while your organization goes through the quality process. “Change is a long-term strategy. Nothing happens quickly,” he says.

Maureen Larkin is quality editor with HealthLeaders magazine. She can be reached at


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