Including senior leaders in CAUTI prevention is a critical aspect of the design and implementation of infection prevention programs.
Editor's Note: This is an excerpt from the upcoming book Preventing Catheter-Associated Urinary Tract Infections by Shannon Davila, RN, MSN, CIC, CPHQ.
Implementing a program to successfully reduce catheter-associated urinary tract infections requires a multipronged approach, dedicated resources, and leadership support from the highest levels of an organization. Senior leaders of healthcare organizations are responsible for navigating the constantly changing landscape of healthcare quality, financial, and regulatory issues.
Outlined in the 2009 National Action Plan to Prevent Health Care-Associated Infections: Roadmap to Elimination, the role of clinical leaders, executives, and administrators is defined as leading the patient safety effort within an institution to implement a safety culture that frontline staff and patients experience at the bedside. Implementing a safety culture is a complex process, and senior leaders need to be at forefront of this effort.
The importance of including senior leaders in CAUTI prevention has been highlighted as a critical aspect of the design and implementation of infection prevention programs. To be in compliance with the Conditions of Participation, CMS requires hospital leadership, including the chief executive officer, medical staff, and director of nursing services, to ensure the implementation of corrective action plans in affected problem areas, including CAUTI prevention. Teams must work collaboratively with senior leadership to address this requirement as well as the many evidence-based clinical requirements for patient care.
Importance of Safety Culture
In the Institute of Medicine report To Err is Human: Building a Better Healthcare System, one of the key improvement strategies outlined how healthcare organizations need to create safety systems that ensure safe practices at the care delivery level. This "culture of safety" incorporates principles and systems that improve the reliability of care, standardize clinical practices, improve the safety of working conditions, and continuously monitor patient safety outcomes.
A culture of safety recognizes risk, addresses safety events with a blame-free approach, and engages frontline staff in the identification of safety concerns and development of solutions. Organizations with a poor safety culture are more likely to demonstrate lack of teamwork and communication and have an environment in which staff are hesitant to report safety concerns for fear of blame. Leaders of healthcare organizations are responsible for instilling safety culture principles at all levels of the organization and providing the resources for these systems to be successfully implemented.
A strong safety culture is important to the success and sustainment of any healthcare quality improvement initiative. If healthcare staff do not feel supported by leadership or demonstrate a lack of trust in the safety systems, implementing improvement processes will be challenging. To assess the current safety culture of an organization, CAUTI prevention teams should administer an assessment to better understand the specific challenges they may face.
The Hospital Survey on Patient Safety Culture (HSOPS) is a useful tool to measure the critical aspects of an organization's safety culture. The HSOPS, developed by AHRQ, is a validated survey tool that measures staff perception of safety for 12 composite areas:
- Teamwork within and across units
- Supervisor/manager expectations and actions promoting patient safety
- Organizational learning and continuous improvement
- Management support for patient safety
- Overall perceptions of patient safety
- Feedback and communication about errors
- Communication openness
- Frequency of events reported
- Handoffs and transitions
- Nonpunitive response to errors
Among these composite safety areas, there are several statements that directly address hospital wide safety issues and, specifically, hospital leadership issues. When completing the survey, staff are asked to rate how they feel about each statement, on a scale from strongly disagree to strongly agree.
CAUTI prevention teams should review the responses that healthcare workers provide for these statements and use them to identify areas where opportunities to improve may exist. For example, if the majority of responses indicate they strongly disagree with question F1. Hospital management provides a work climate that promotes patient safety, CAUTI prevention teams should consider that a major barrier to improvement efforts and develop implementation plans that deal directly with that challenge.
It is recommended that healthcare organizations administer the HSOPS on a regular basis to measure trends and results. AHRQ provides several free resources to assist healthcare organizations analyze and interpret the survey results. CAUTI teams can download the complete survey and data analysis tools by visiting the AHRQ HSOPS website.
Engaging Senior Leaders in CAUTI Prevention
Dr. Sanjay Saint, an internationally recognized expert and leader in infection prevention, implementation science, and patient safety, has studied the qualities of successful leaders. He determined that leaders from hospitals who are engaged in HAI prevention exhibit the following attributes:
- Develop and sustain a culture that supports clinical excellence and convey that the importance of safety culture to the staff.
- Overcome barriers and challenges to HAI prevention, including difficult or resistant staff.
- Inspire others within the organization.
- Use their position to strategically develop partnerships and gain support for local HAI prevention initiatives.
When implementing a CAUTI prevention program, it is vital to have senior leaders who support the team and frontline staff. Depending on the organizational structure, this type of leader can serve in a variety of positions. Usually, an executive leader is in at a vice president level or higher position, and when recruiting a leader to support CAUTI prevention, teams may look to the chief nursing officer or chief medical officer when possible. However, while the senior leader should have a clinical interest in CAUTI prevention, he or she does not need to be a clinician to be effective in his or her role.
Having a senior leader on a CAUTI prevention team is advised, but if the team is unable to secure someone in an executive position, other leaders within an organization can still be effective. Department directors, managers, and chiefs should be considered as alternatives to an executive. Regardless of the leader's title, teams should seek out leaders who are solution-oriented, have experience with overcoming barriers, and are open to learning from and engaging with frontline staff.
When recruiting a senior leader to assist in CAUTI prevention activities, teams should be prepared to clearly outline the aspects of the role, what the time requirements will be, and any other important expectations. Senior leaders will be expected to work closely with the project team to achieve the following:
- Create the project mission, goals, and timelines.
- Confirm necessary staff and processes are in place for project implementation.
- Ensure that essential resources are made available to support the project.
- Verify that decision-making and problem-solving processes are clear.
- Ensure that a measurement and evaluation process is in place.
This type of checklist can be modified as the CAUTI prevention team progresses through the project and the senior leader's role expands or changes, or as changes are made to the implementation process. Checklists are an effective organizational tool to assign responsibility for tasks and keep teams and individuals on track.
Leveraging Senior Leaders to Engage Frontline Staff
The CUSP model for improvement has been used extensively in HAI prevention programs, including CAUTI prevention. CUSP is aimed at supporting teams to address safety issues at the unit level. The model emphasizes how leaders can support teams through both technical and socioadaptive strategies.
Technical strategies for CAUTI prevention include intervention that relate to the clinical and epidemiologic aspects of infection prevention, including adopting clinical criteria for appropriate catheter use and providing equipment or supplies that are necessary for aseptic catheter insertion and maintenance. The socioadaptive strategies support the development and maintenance of a positive safety culture. These strategies include providing support to nurture open communication and teamwork, addressing challenges the CAUTI team may face, and being actively involved in developing solutions to address safety concerns.
While these strategies may seem straightforward, it can be challenging for senior leaders to implement them. Through years of patient safety research and project implementation, tools have been developed to help senior leaders be more effective in their staff engagement efforts. Two examples of these tools, the Staff Safety Assessment and leadership rounds, are described below.
Staff Safety Assessment
Developed through the CUSP model, the Staff Safety Assessment is a simple way for leaders to keep current on the safety issues that frontline staff identify as priorities. The Staff Safety Assessment is made up of two questions:
- How will the next patient on our unit be harmed?
- What can we do to prevent that harm from happening?
Senior leaders and CAUTI prevention teams should regularly ask frontline staff to answer these questions. The assessment can be administered as an anonymous survey or used as a discussion topic in a group setting. Project leaders should review the results of the Staff Safety Assessment and share feedback with team members. Involving frontline staff in this type of safety assessment is a strategy to gain valuable insight into safety risks and helps leaders prioritize those risks and develop safety improvement plans.
Leadership rounds are another tool that can be used to help leaders engage with frontline staff. When senior leaders meet regularly with frontline staff at the unit location, it improves their visibility and connects them to the real issues that frontline staff deal with on a daily basis. The rounds provide an opportunity for leaders and unit-based staff to have an open discussion and to provide real-time feedback to each other about CAUTI prevention activities. Leaders can use this this face-to-face time to reinforce CAUTI prevention goals with the clinicians who are directly involved in the care of patients.
A team of researchers at the University of Washington Health System found the leadership rounds to be so successful at reducing CAUTIs that they implemented them for central line–associated bloodstream infections and Clostridium difficile infections. Additionally, staff reported their satisfaction with having the opportunity to have regular interactions with members of the leadership team.
CAUTI prevention teams should work with senior leaders in the planning of leadership rounds, including meeting with leaders before the rounds to share any unit-specific data or concerns. Frontline staff should also be briefed ahead of the rounds so that they understand the purpose and are prepared to share their concerns and recommendations for improvement. It might be helpful for a team member to document topics that are raised in the rounds so that they can be reviewed later.
Senior leaders must be at the forefront of infection prevention initiatives.
If staff members lack trust in safety systems, process improvement will be a challenge.
Having a senior leader on the CAUTI prevention team is advised, but they do not have to be a clinician to be an effective leader.