When the North Shore-Long Island Jewish Health System (NSLIJHS) in Great Neck, N.Y., sets its sights on achieving as close to a zero tolerance of infections as possible, it knew it faced an intricate and complex journey, but according to Karen Nelson, RN, vice president of clinical excellence and quality, the health system took it in stride as part of its ongoing commitment to excellence. “Leadership has established priorities and set clear expectations,” Nelson explains. “The use of evidence-based best practices, an interdisciplinary approach to care across the continuum, a consistent message from administrative and clinical leaders, staying focused, engaging frontline staff and physicians, rewarding successes, sharing best practices and lessons learned, providing regular feedback utilizing data and benchmarks are the keys to success. We’ve set our benchmarks at the top decile of performance nationwide.”
NSLIJ Health System hospitals signed on to the Institute for Healthcare Improvement (IHI)’s 100,000 Lives Campaign in addition to launching a central line-related iInitiative as commitment to system-wide philosophy of zero tolerance for healthcare-acquired infections (HAIs). Hospitals included in the campaign are: Forest Hills, Franklin, Glen Cove, Huntington, Long Island Jewish Medical Center, North Shore University Hospital-Manhasset, Plainview, Schneider Children’s, Southside, Staten Island and Syosset.
The improvement initiative upon which NSLIJHS embarked was designed to increase the quality of care and decrease HAIs by standardizing best-practice approaches used throughout the health system. “NSLIJ has developed a consistent methodology and rigorous monitoring procedure to manage the process of care and control the incidence of infection,” Nelson says. “Leadership prioritized, with the use of measurement, an integrated approach to standardize infection control practices. One area of focus was on our rates of central line-associated bacteremias (CLABs), which were examined to improve patient care and safety in 22 intensive care units (ICUs), encompassing over 330 ICU beds. This approach included standardizing evidence-based infection control practices, policies and procedures, reporting and training modules. A root-cause analysis is conducted when a CLAB occurs to assess opportunities for improvement. In addition, each site reviews collected CLAB data in the unit-based interdisciplinary forums, site specific Performance Improvement Coordinating Group (PICG), and Health System PICG. The message of zero tolerance was spread to all employees through these surveillance efforts, as well as through the intranet, collaborative care councils, and newsletter articles. The outcome of this targeted intervention has resulted in a 60.3 percent decrease in the CLABS rate from 2004 to 2008. In addition, central line days decreased by 8.7 percent. Zero is achievable and this has been demonstrated by several units across our health system. Staff can tell you how many days it has been since the last infection on their unit.”
Nelson says that physician and nursing leaders partnered to co-chair the clinical initiatives, utilized data to review performance, and reduced variation in care through use of evidence-based guidelines and ensure patient safety. “We developed tools for the improvement of care coordination, and through our collaborative care model we engage patients and their families. Standardization of educational material, which is available on the health system’s intranet, videos, equipment and a non-punitive approach was also key.”
A sophisticated, comprehensive educational outreach was central to NSLIJHS’s success. “The Center for Learning and Innovation (CLI), NSLIJ’s corporate university, continues to be the largest of its type, having an annual attendance of over 14,000 students,” Nelson says. “CLI has several divisions, including its Patient Safety Institute (PSI) and Operational Performance Solutions division. Employees are instructed by master black belt mentors in various process improvement methodologies, including LEAN and Six Sigma. Project outcomes are reported to senior leadership. CLI monitors its programs through student feedback and annual learning needs assessments. Educational programs are also evaluated back at the workplace to ensure the material learned in the class is used on the job. PSI features full-scale patient simulators comprised of computer-based, interactive technology, and digitally-enhanced mannequins. All simulations are video recorded and reviewed during post-scenario debriefings, creating a safe environment for enhancing clinical competency and teamwork.”
This level of improvement is not possible without maintaining an institutional culture that can uphold patient safety mandates, make infection prevention a priority, and achieve buy-in from all stakeholders. “The organization has a culture of both internal and external transparency and was one of the first health systems to post our infection rates on the public Web site,” Nelson emphasizes. “This also promotes accountability. System-wide initiatives to improve health outcomes and reduce unnecessary variations in care are further strengthened by the focus on internal transparency and patient safety, innovation and use of technology. For example, a new hand hygiene project involves an automatic performance feedback loop that issues alerts when staff are not in compliance. In this program, remotely monitored video cameras are used to assess and calculate compliance in hand hygiene events (using soap and water or an alcohol-based hand sanitizer). Real-time performance feedback is transmitted every 10 minutes and displayed on two separate LED boards in the unit. The unit’s nurse managers and attending physicians receive more detailed analyses via e-mail twice a day and aggregated reports weekly. The reports compare hand hygiene compliance among rooms, between physicians and other healthcare professionals, and monitor changing compliance rates on an hour-by-hour, day-of-week and shift basis. Hand hygiene rates improved by 81 percent when feedback was initiated, and a downward trend of methicillin-resistant Staphylococcus aureus (MRSA) transmission (greater than 60 percent) was confirmed. Continuous feedback plus the presence of video cameras produced and continues to produce a significant and sustained improvement in hand hygiene compliance. To ensure that members of the community (patients’ family members and other visitors) do their part, a comprehensive hand hygiene education program was rolled out at all of our sites through collaboration with staff at patient registration, admitting areas, emergency departments, and outpatient areas. Hand hygiene compliance rates are another example of data available to the general public via our Web site. The purpose of the real-time performance feedback, is not punitive for noncompliant individuals. It’s about creating enhanced awareness and constant feedback.”
Nelson continues, “The message is clear, patient safety is everyone’s responsibility. People want to do the right thing. They want to provide the best care to their patients, physicians and frontline staff at the bedside. Involving caregivers in any process that you’re looking to change, being a voice at the table helps give you the buy in and results. It cannot be a mandate from leadership, it is imperative that you engage and empower the stakeholders.”