Nurse-Sensitive Indicator Quality Improvement Toolkit: A Scalable Solution to Improve Health Care–Associated Infections : Journal of Nursing Care Quality

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Nurse-Sensitive Indicator Quality Improvement Toolkit

A Scalable Solution to Improve Health Care–Associated Infections

McVey, Caitlin MBA, RN, CPHQ, CLSSBB; von Wenckstern, Toni MSN, RN; Mills, Courtney MSN, RN, NE-BC; Yager, Lauren MBA, RN, RNC-NIC; McCauley, Christopher MSN, RN; Rivera, Yvana MPH, CIC; Reed, Elizabeth BSN, RN, CIC

Author Information
doi: 10.1097/NCQ.0000000000000634


Central line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are prevalent health care–associated infections (HAIs) that are considered preventable and increase the patients' risk of prolonged hospital stays, morbidity, and mortality.1,2 For the past decade, preventing HAIs has been a focus among health care organizations, leading to evidence-based practice bundle creation and many quality improvement initiatives.1,2

During the 2020-2021 COVID-19 pandemic, many existing best practices became challenged by patient comorbidities and susceptibility toward infections, as well as an increase in travel nursing staff.1,2 A review of 148 US hospitals revealed a dramatic increase in HAIs in 2020 aligned with the increased burden caused by COVID-19 surges.1 From March 1, 2020, to December 31, 2020, these hospitals reported a 60% increase in CLABSIs and a 43% increase in CAUTIs. During the COVID-19 pandemic, hospitals also faced resource constraints as many support personnel were called to assist at the bedside with increased patient volumes.1

A Magnet-designated, large, academic, level 1 trauma center in Houston, Texas, experienced the same challenges during the COVID-19 pandemic. The hospital's chief nursing officer (CNO) assigned nursing leadership to find a solution to increasing HAI concerns in the first few months of the COVID-19 pandemic. A new tool was needed to support these efforts without causing further strain on vital resources. Existing best practices and strategies including data visualization solutions3–5 to monitor and prevent HAIs were not feasible to maintain during the pandemic surges. This article describes the novel Nurse-Sensitive Indicator Quality Improvement (NSIQI) Toolkit, as well as the development and implementation process, and discusses how this scalable solution can be implemented at any health care organization.


Toolkit development

Nurses and infection preventionists partnered to review the literature and evaluate existing evidence-based practices. Nurse leaders and staff gained feedback on previously implemented best practices through unit rounding and Shared Governance Councils. Nursing leaders adapted data visualization and Kamishibai card best practices3–9 for sustained HAI reductions and combined methods to create the NSIQI Toolkit. Kamishibai cards, often called K-cards, originated in Japanese Buddhist temples as a form of visual narration.10 Over time, this concept has been adapted and used as part of the Toyota Production System and other Lean management processes as visual controls for process audits using green and red colors to indicate if a process step passed inspection or not.10 K-cards provides a method to assess process steps for compliance, allowing noncompliance findings to be focused on failure points within the process or system, instead of the person.11

K-cards were previously piloted in one of the hospital's intensive care units; however, staff feedback showed a lack of understanding, confusion, and disconnect with the process. In addition, the literature suggests traditional K-cards may require longer implementation times and increased resources for sustained success.9 Therefore, nursing leaders identified the need to adapt K-cards6–9,11 and other evidence-based practices3–5 to create the NSIQI Toolkit. Once created, the NSIQI Toolkit and associated processes were discussed and refined by frontline staff in the Shared Governance Council and Unit Practice Council Structures. The NSIQI Toolkit design increased the ease of implementation and provided data transparency and visualization4,5 to frontline staff and unit leaders. Data transparency and easy visualization were critical to invoking positive change, especially with a large volume of travel nurses on the unit.

Toolkit description

The NSIQI Toolkit comprises 2 primary documents: Zero Boards and Report Cards. The Zero Boards track lag measures based on essential patient safety indicators, including days-since-last event and incidents of event occurrence. The Zero Boards, depicted in Supplemental Digital Content, Figure 1 (available at:, were developed on the basis of the hospital's National Database of Nursing Quality Indicators (NDNQI) data submission elements. The Zero Boards tracked CLABSIs, CAUTIs, hospital-acquired pressure injuries (HAPIs), and falls with injury. An additional blank line was included on the Zero Boards for units to add a unit-specific metric. Nurses used the Zero Boards to visualize annual data trends and focus on areas that need improvement for the unit. The team adapted traditional Kamishibai tools into Report Cards6–9 based on nurses' feedback to simplify the auditing process of critical indicators. The Report Cards, depicted in Supplemental Digital Content, Figure 2 (available at:, tracked lead measures based on high-risk, nurse-driven bundle elements. Lead measures on the CAUTI report card were documented in the electronic health record (EHR) and included observations for Foley tubing with dependent loops, completed Foley catheter and perineum hygiene care, and the evaluation of Foley catheter necessity. Similarly, lead measures on the CLABSI report card could be found in the EHR and included an occlusive and intact dressing with appropriate labeling, nurse evaluation of line necessity, and a visual audit of the required 30-second catheter hub cleaning. Staff audited these measures each shift, scoring them as 1 or 0 based on compliance. The scores of each bundle element were summed to create a letter grade (A-F) for that shift.

The process

Each unit was required to have a Zero Board posted near the charge nurse station. An assigned nurse on the unit updated the Zero Board daily. If a tracked event (eg, CLABSI, CAUTI) had occurred on the unit in the past year, the unit was required to have a Report Card for that metric. Each shift, an assigned nurse would complete 1 visual audit on 1 patient and update the Report Card based on the audit results. The daily letter grades depicted how the unit was performing overall, and the individual lead measure scores showed which elements were the opportunities for improvement. Only completing 1 audit per shift reduced the time and resource needs, which aided in process sustainability. Despite limiting the number of required audits each shift, the Report Cards still collected meaningful data through a total of 60 audits per month (30 on day shift and 30 on night shift). Nurse leaders used the lead and lag measures to create focused action plans to target the improvement opportunities identified on the Report Cards.


The hospital's CNO assigned nursing leaders with quick implementation of the new NSIQI Toolkit. Nurse educators and frontline staff partnered to create a 1-page educational handout to facilitate rapid implementation. The educational handout described the toolkit's purpose, how to complete the audits, and included pictures depicting the process. This handout circumvented the need for extensive training because it provided staff just-in-time training with a simple resource to refer to as needed. In addition, a detailed communication plan outlined the numerous communication methods for implementing the toolkit, including unit-based council meetings, staff meetings, handouts, unit huddles, email, and leader rounding. Communication occurred through shared governance council meetings, leadership meetings, unit-based practice council meetings, educator forums, staff huddles, staff meetings, and emails. The information was provided 7 times in the aforementioned 7 ways over 2 weeks.

In the initial rollout, nurses used dry-erase tool sheets created by printing and laminating the templates on legal-size paper. This format provided a timely, cost-effective resource to support the immediate implementation need with minimal resource constraints. This format also allowed the units to customize their tools. The team created comprehensive implementation packages to increase the ease of implementation for unit leaders. The implementation packages included the educational handouts, printed dry-erase tool sheets, markers, and wall-mounting materials. The implementation packages facilitated quick and easy adoption as they included all needed materials to start the process.

The project team used adapted leader rounding guides12 to support the NSIQI Toolkit implementation, signal the importance of the new process, and sustain the initiative. The leader rounding guide, depicted in Supplemental Digital Content, Figure 3 (available at:, provided leaders with a structured process and questions on how to talk to staff about the toolkit, the expectation of the unit staff in completing the toolkit materials, and ways to support staff in the implementation process. The project team assigned leaders to specific units for rounding. For 2 weeks, leaders rounded on their assigned unit daily, Monday through Friday. After 2 weeks, the rounding decreased to weekly for 1 month before becoming monthly. The leader rounding provided an opportunity for just-in-time training with the staff and process reinforcement as needed. The consistency in leader rounding increased compliance with the toolkit's implementation, mitigating the potential barrier of the quick turnaround time requirement.


Although the Zero Boards tracked 4 nurse-sensitive indicators, Report Cards were initially created for CLABSIs and CAUTIs. These 2 indicators were measured for improvement as part of this project, while additional Report Cards were created for the remaining measures of HAPIs and falls with injury. National Healthcare Safety Network (NHSN) reportable CLABSI and CAUTI data were collected each month across the hospital. The process for collecting these data, including definitions and infection criteria, followed NHSN standards and did not change during the baseline, implementation, or control periods. This process was in place prior to the NSIQI Toolkit's creation and implementation.


The number of CLABSIs and CAUTIs was analyzed with the number of central line and Foley-catheter days (ie, device days) by month to calculate the incident rate of infections per 1000 device-days. The standardized infection ratio (SIR) was also used to compare the number of observed infections with the number of risk-adjusted expected infections. Data were grouped into baseline and 10-month postintervention time frames. The CAUTI intervention was implemented first with a baseline of January 2020 to September 2020 and postintervention of October 2020 to July 2021. The CLABSI intervention had a baseline of January 2020 to October 2020 and 10-month postintervention of November 2020 to August 2021 time frames. Descriptive analyses of the rate and SIR calculations were used to compare the baseline and postintervention data.


Hospital-wide CLABSI and CAUTI rates were reduced over time following the introduction of the NSIQI Toolkit with sustained results. The CLABSI SIR decreased by 19% and the CAUTI SIR decreased by 19.4% in the 10-month postintervention period. The CLABSI rate decreased by 14% in the postintervention data time frame, as shown in Figure 1, by month comparing the pre- and post-CLABSI data. The CAUTI rate also decreased by 18% in the postintervention time frame, as depicted in Figure 2, by month comparing the pre- and post-CAUTI data. In addition to improved infection rates, staff reported increased awareness of lead measure compliance and enhanced focus around nurse-sensitive infection prevention bundle elements.

Figure 1.:
NHSN-reportable CLABSI rate impact. NHSN indicates National Healthcare Safety Network; CLABSI, central line–associate bloodstream infection; UCL, upper control limit; LB, lower bound.
Figure 2.:
NHSN-reportable CAUTI rate impact. NHSN indicates National Healthcare Safety Network; CAUTI, catheter-associated urinary tract infection; UCL, upper control limit; LB, lower bound.


The COVID-19 pandemic and ongoing nursing shortage have constrained hospital resources and challenged existing evidence-based practices to track and improve nurse-sensitive indicators. The NSIQI Toolkit provides a simple yet effective solution that can be deployed at the point of care to trend lead and lag nurse-sensitive measures. The CLABSI and CAUTI SIR and infection rates decreased after implementing the NSIQI Toolkit. The findings from this project are consistent with other findings in the literature with the use of K-cards and Lean daily management systems.3–8 However, the NSIQI Toolkit's format received better feedback than previous K-card attempts and was found to be more adaptable to nurses' workflows and understandable without extensive training.

The NSIQI Toolkit has the potential to be scalable and reproducible across health care organizations, regardless of resources, unit configuration, and processes. The toolkit's format creates an inexpensive product that can be utilized anywhere on a nursing unit without large space requirements or concerns of wall damage. The tool's format can be adapted to fit a variety of display needs, including digital display boards and interactive whiteboards. The original tool was formatted to a standard legal-size document in a word processing system and can be customized by building the format with other display and processing systems to meet the needs of organizational leaders. Utilizing digital display boards can assist in the automation of the tool, further enhancing its ease of use. However, this is not necessary for success, evidenced by the stated HAI-reduction outcomes. In addition, the tool is customizable to meet the nursing and non-nursing changing needs of the organization. Organizations can adapt the NSIQI Toolkit to focus on any nurse-sensitive indicators such as patient falls or HAPI prevention. The inexpensive nature of the toolkit, ease of implementation, and ability to customize the tool's focus promote scalability across organizations.


A limitation of this study is the use of descriptive analyses of the outcome data. Future evaluations may use larger samples and correlational analysis to explore the relationships between the toolkit implementation and nurse-sensitive quality outcomes in a more robust way. In addition, this improvement project was conducted at one health care organization and may not be generalizable beyond similar institutions. Further studies may resolve this limitation.


Nurses created the NSIQI Toolkit to improve and sustain nurse-sensitive quality indicators at the point of care. The reduction in the CLABSI and CAUTI SIR and infection rates occurred and was sustained through multiple COVID-19 surges when other health care organizations were experiencing an increase in infections. The tool's simple format, ease of use, and data visualization capabilities provide nurses, leaders, and organizations solutions to improve patient care sustainably. In addition, the flexible format increases leaders' ability to adapt, modify, and scale the toolkit to meet their organization's needs. The NSIQI Toolkit provides a practical template to meaningfully reduce hospital-acquired infections and improve patient outcomes.


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clinical audits; Kamishibai card; nurse-sensitive indicators; quality improvement toolkit

Supplemental Digital Content

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