Practice Changes in ICUs Face Common Barriers: A Q&A with Amber Welsh, PhD

Researchers from Indiana University have identified common barriers and strategies for successfully implementing practice changes in intensive care units (ICUs).

By Kelly M. Pyrek

Researchers from Indiana University have identified common barriers and strategies for successfully implementing practice changes in intensive care units (ICUs). The study, published in the August issue of Infection Control and Hospital Epidemiology, reveals shared lessons learned from six ICUs as they implemented evidence-based practices to reduce methicillin-resistant Staphylococcus aureus (MRSA) infections.

In 2006, five Indianapolis-area hospitals began a systematic implementation of practices known to reduce the spread of MRSA, including active surveillance, hand hygiene, patient isolation, and the use of protective equipment like gowns and gloves. A group of researchers led by Dr. Brad Doebbeling then interviewed team members from each hospital to identify common themes of successful implementation shared by all hospitals.

The interviews produced five core themes common to all hospitals: 
- Engage front line staff in implementation.
- Build a multi-disciplinary implementation team.
- Commit to data collection, management, and feedback.
- Acquire support of top management.
- Use process mapping and other problem-solving tools.

Amber Welsh, PhD, of the Indiana University Center for Health Services & Research Outcomes, shares her thoughts on this research.

Q: Why do you think that bundle implementation in the ICU so challenging?

A: I believe bundle implementation (and all that goes with it) is so challenging in ICUs because in those units in particular, healthcare workers are in survival mode not only due to the nature of their patients' acuity but also due to staff reductions, supply limitations and a focus on cost reduction in our current economy. When a person is in survival mode, their absorptive capacity is reduced and two things happen.  People tend to rely on habitual responses because they don't have the mental space to learn something new. Its a documented fact that patients die with reduced nursing attention. We know it takes more time to learn something new but in these tough economic times, ICU personnel are given fewer resources (i.e., no aides) not more, thus they have less mental space to focus on learning something new. If a hospital wants to implement change in ICUs, one suggestion is to provide help in the form of aides to the nursing staff and physicians for the initial six months of implementation so they would have the absorptive capacity to learn the new procedures. 
Q: Your study underscores the importance of clinical team buy-in as well as support and leadership from the institutions C-suite what do you believe were the keys to securing both?
A: First, it isn't just about securing support from the C-suite. In another study, "Reducing healthcare-associated infections (HAIs): Lessons learned from a national collaborative of regional HAI programs," which was published in the August issue of AJIC, we interviewed five collaboratives consisting of 33 hospitals. One finding relevant to this conversation was that it took BOTH top-down and bottom-up support for positive, effective implementation. Top-down support is the C-suite to which you refer and they are needed to legitimize the project as well as fund needed resources and supplies. However, equally important is the commitment and involvement of unit leadership because they motivate employees to be involved, give them the time to do it as well as provide the consequences of non-compliance (to nursing personnel; sometimes to physician personnel as well).

Clinical team buy-in is accomplished in a number of ways and multiple avenues is recommended for different populations of people. All of the following techniques were used to engage frontline staff:  indentify unit champions and involve them in decision-making; include other frontline employees on the implementation team; have unit Q&A and/or educational sessions (called "kick-off events"); ask staff members if they believe infection transmission is a problem, what ideas they have for stopping it and what they think the barriers are; posting the implementation team's work (i.e., process maps, implementation plans, etc.) in the staff lunch room and ask staff to offer suggestions and changes; share personnel stories of infection transmission either regarding themselves, or regarding patients; create videos using staff as actors (they love to ham it up! Include a few physicians in this.), etc. 

For physicians specifically, the infectious disease director would speak at physician meetings about this project and try to recruit physicians that way.  Another hospital created a "three strikes you're out" consequence program for non-compliant physicians in that if a physician was not compliant, a nurse would tell his/her medical director who would then send a letter to that physician. On the third non-compliant report, the physician was required to meet with the chief medical officer for a discussion about non-compliance. I'm not sure what happened after that if the physician continued to be non-compliant. This hospital was implementing this program as we were closing down the study so I have no success stories to report with this endeavor. However, I thought it was necessary and courageous of this hospital to attempt a repercussions program because no other hospital did that.

To summarize:  the keys to clinical buy-in and leadership support (both c-suite and local level) is to know your culture - (1) know who is an influencer and involve them; ask staff for their opinions and implement their suggestions; use many methods of involvement because different things will work with different populations; make it personal -- use personnel stories, pictures or videos; collect the data needed to made a business case for the effort, and most importantly, be committed -- give the implementation team the money, staff and time to do what they need to do and then, leaders should ask employees about their efforts, show interest in the project, advertise/talk about their successes.  Interest shown begets interest grown.   
Q: You cite non-compliance and burnout to be significant impediments to the process is that caused by the inherent challenges of bundle implementation referenced previously, or is it a byproduct of behavior that can addressed with a culture change?
A: Inherent challenges of bundle implementation (i.e., human behavior change, supply acquisition, process change) versus culture change... I don't think it is an "either/or" question. I believe that as one implements any process change requiring human behavior change that it will inherently involve some change in culture. For example, to move from an environment that doesn't really care about infection transmission to an environment that has zero tolerance for infection transmission, one MUST change the attitudes of all relevant healthcare workers including transport and dietary personnel, as well as the attitudes of patients and families.

 A very real outcome of all this attitude change is that you will change the culture to be one that prides itself on 365-plus days of zero transmissions. Thus, which came first -- bundle implementation or culture change? It doesn't matter because to change one effectively means to change the other. The trick is which should an implementation team go after first -- bundle implementation (process and behavior change) or attitude change? We found that it is easier sometimes to facilitate a change in behavior via forcing functions ("you must wash your hands upon entry and exit of any patient room") rather than to try to change attitudes directly. Sometimes a change in behavior leads to a change in attitude. There will, however, be those individuals who will remain non-compliant (because their attitudes do not support the new change). It is with these individuals that a change in attitude must be addressed directly.  This can be done via research articles summarized for the physician demonstrating the value of the new behaviors, thought leader presentations, conferences, etc.

 In the end, though, one will always have those stubborn individuals who refuse to change (behavior or attitude) no matter what you do and it is with these individuals that hospital leadership must decide how they wish to handle them.  One cannot force an attitude change but one can force a behavior change.
Q: What can infection preventionists do to help facilitate programs that foster better interventions at the local level?

A: Collect good data to support the value of infection reduction. Provide ongoing education sessions for clinical and non-clinical personnel on how easily infections are spread. Routinely share data with leadership teams on infection rates and activities to reduce them. Benchmark other hospitals -- collect standards and ideas. Collect and summarize articles on infection reduction techniques and disseminate the summaries.
Q: Data seems to be coming from everywhere these days how can clinicians/infection preventionists better harness the power of this data and use it to improve patient outcomes?

A: Maintain a data role on the infection control team. This person collates, analyzes, summarizes and publishes the data (by unit, by infection, etc.) If a data role cannot be funded, consider creating an unpaid six-month intern role for statisticians, infection control students, nurses looking to grow, etc. Purchase data-mining packages. Create Excel spreadsheets for data management.  

Reference: Welsh CA, Flanagan ME, Kiess C and Doebbeling B. Implementing the MRSA Bundle in ICUs: One City-Wide Collaboratives Key Lessons Learned. Infection Control and Hospital Epidemiology 32:8