HUMAN ERROR is never easy to accept, but understanding the process and changing the culture of response is one way to minimize risk. Chasing excellence is a challenge and achieving perfection may be impossible, but healthcare professionals are obligated to prevent avoidable errors that are detrimental and potentially fatal for patients. This article shares the journey of a specialty unit that recognized infection prevention opportunities related to drug-resistant hospital-acquired infections (HAIs) and explains how the healthcare staff successfully clarified and restructured clinical practices to reduce risks, sustain results, and ultimately change the department's culture surrounding human error.
In the authors' experience at their facility, HAIs lead to negative outcomes for patients regardless of age and present a significant challenge. Although many guidelines, protocols, and policies are designed to limit patient risk, infections can still occur due to unclear practices and human error. Healthcare professionals must recognize and understand patient safety expectations.
A specialty unit at a New Jersey healthcare facility recognized the occurrence of 16 infections over a 2-year period. They identified the risk of cross-transmission and outbreaks of drug-resistant HAIs during root cause analysis and recognized an opportunity to improve infection prevention by implementing best practices. Success was structured as the responsibility of the hospital administrative team, and patient risk was reduced through new infection control protocols that encompassed:
- staff education
- validation of skills
- frontline clinical staff accountability
- continued focus to sustain successful practices.
Utilizing the PDSA cycle
Originating in Walter Shewhart and Edward Deming's articulation of iterative processes, plan, do, study, act (the PDSA cycle, also known as the four stages of the PDSA cycle) has been widely accepted in healthcare improvement. It has been used interchangeably with plan, do, check, act terminology, but the authors will refer to the methodologies as PDSA cycles for the purpose of this article.1,2
PDSA cycles support teams with a structure for testing to enhance overall quality of care and improve outcomes. The plan stage focuses on identifying an improvement change. The do stage implements the planned change and tests it. The study stage evaluates success by analyzing data collected in testing. The act stage identifies future opportunities and next steps to inform a new PDSA cycle.1
Although the source of drug-resistant HAIs was never identified, the likely hypothesis was cross-transmission based on root cause analysis, which included observation and collaboration with infectious disease specialists. As such, the goal of the PDSA cycle was to implement practices to minimize cross-transmission.
The plan stage is directed toward planning changes that will yield improvement. For our project, this phase incorporated basic infection prevention practices with a focus on the following:
- Hand hygiene. Healthcare professionals provide a pathway for cross-transmission of nonairborne organisms between patients who are not in direct contact with each other. A lack of proper hand hygiene is one of the highest correlations for HAIs.3 Consequently, stringent hand hygiene practices were incorporated into the plan.
The emphasis on hand hygiene could not simply address the importance of staff washing their hands, as this approach had been completed before and demonstrated only short-term success. Instead, proper technique became the focus. The new hand hygiene protocol followed guidelines from the CDC and the World Health Organization (WHO) for length of time and coverage of all hand surfaces, respectively.4,5
- Equipment cleaning. Because inadequate cleaning of bedside equipment was identified as a source of risk, a structure was put into place to ensure that all bedside equipment was cleaned appropriately according to instructions for use. All equipment was wiped down by the assigned nursing staff each shift. This process was validated through regular surveillance from nursing leadership.
- Patient screening for infection or colonization. Patients were screened upon admission and then every Sunday during their stay. The screening was completed by the nursing staff via active surveillance cultures to identify methicillin-resistant Staphylococcus aureus. Those with acute infections and those who were colonized were cohorted.
- PPE technique. Initially, all patients in the department were placed on contact precautions until the updated infection prevention practices became commonplace, so ensuring proper techniques for donning and doffing personal protective equipment (PPE) became an area of concentration for the healthcare staff.
- Staff surveillance. Surveillance was initiated to monitor hand hygiene, PPE technique, and equipment cleaning for all staff shifts and specialties within the department (see Action plan).
Stakeholders were identified as all individuals who entered the department, including clinical and nonclinical staff, and were held accountable. A skills fair was held for the facility staff. With assistance from nurse educators, the infection prevention team taught evidence-based practices for hand hygiene, PPE, and equipment cleaning. All clinical, nonclinical, and ancillary staff was responsible for completing the training. Nurse educators documented and ensured comprehension using the teach-back method, in which the staff demonstrated these practices without error.
Nursing leadership teams initiated surveillance. Due to concerns regarding retaliation, accountability, and objectivity in the early stages of implementation, clinical nurses did not survey each other. Instead, the surveillance team was composed of leaders from multiple units, including vice presidents, directors, and managers. Later, nurse educators also served in these roles when additional help was needed.
Unit medical directors coordinated with infectious disease specialists and the lab director to develop the weekly screening process. The new process required additional resources, and medical and administrative leadership developed standard operating procedures, which included additional testing orders, culture collection, and sample processing. All results were reported directly to the infection prevention department and subsequently communicated to the units.
The do stage implemented the planned changes and tested them (see Facility protocols). Skills fairs, which included didactic and teach-back methods, occurred before each shift until most of the staff had completed their training. The education covered hand hygiene with soap and water in addition to gel practices, PPE donning and doffing, and equipment cleaning. Additional education was scheduled as needed. New employees were required to complete training before joining the department.
After the first training session, staff surveillance was put into effect immediately. This consisted of 10 hand hygiene audits, 10 PPE audits, and 10 audits on equipment cleaning. Staff who made individual errors were coached in real time, and continued failure to follow the new protocols resulted in disciplinary action.
Monitoring families and visitors and keeping them informed about the importance of infection prevention was critical. As the plan was implemented, all patients were placed under contact isolation and cohorted as appropriate. Visitation was limited temporarily to immediate family only. Families received education on hand hygiene techniques before visiting their relative and signed an affirmation stating that they understood the infection prevention practices.
Weekly routine screening, including cultures, was initiated as a measurement tool to assist with validating success. An infection prevention steering committee managed and directed care related to drug-resistant HAI outbreaks. The team consisted of medical and nursing leadership, infection prevention staff, infectious disease physicians, environmental services, respiratory care leadership, supply chain leadership, regulatory staff, and nurse educators.
Data were collected from staff surveillance weekly and reported to the infection prevention steering committee monthly. The state department of health partnered with the steering committee throughout implementation. Staff was educated on techniques for hand hygiene, PPE donning and doffing, and equipment cleaning. More than 200 observations were completed monthly, and compliance was measured on the correct technique utilized. If the observed staff followed the correct techniques, compliance was 100%; if their technique was incorrect at any point during observation, it was considered noncompliant.
Initially, hand hygiene compliance measured 94% and steadily climbed. PPE observations demonstrated 67% compliance and rose with consistent coaching and accountability. No data had been previously collected on equipment cleaning, as it was a new observation put into place during the skills fair. After 8 months of data collection and more than 10,000 observations, the combined average success rate showed over 90% compliance in all three areas of surveillance.
The leadership team realized that many work hours were necessary to validate and understand patient-care workflows. The team was supported by hospital administration and worked closely with the frontline staff and medical team to identify opportunities and implement changes as needed. Some issues identified during surveillance were systemic. For example, the physical space was adjusted to foster compliance by relocating hand soap or hand gel for easier access. Environmental issues were also addressed, such as the storage of clean items next to dirty items.
Facilitating a change in culture
Healthcare staff may be satisfied with the status quo and reluctant to change, but the leadership at the authors' facility understood that change was necessary to reduce HAIs. The infection prevention protocols put into place were considered must haves. They were long-term processes that would permanently alter the culture and the way in which staff cared for patients. The staff was no longer just cleaning their hands; they were covering all areas of their hands in the time frame determined by the CDC. Change needed to be seen as beneficial, and all stakeholders had to understand the importance of infection prevention and the risks of noncompliance for patients.
Change requires a safe environment for frequent and open communication. Regular infection prevention huddles were established, as well as weekly newsletters to communicate changes and updates to frontline staff. New behaviors had to be sustained through an adjustment in facility culture, and staff leaders led the change efforts by example.6
Lewin's change model, which is often used to explain change in healthcare, has three steps:7
- The first step is unfreezing behavior that needs to change. In this situation, noncompliance and a lack of accountability related to infection prevention guidelines was targeted as the behavior to unfreeze. This step is most difficult when the old ways of doing things are challenged. Convincing arguments were needed to impact staff behaviors, and evidence-based data from the CDC and WHO were used to support those arguments.6
- In the second step, individuals start to believe in implemented changes and look for new ways of doing things. They may even begin to support and embrace the new practices. During this step, staff realized the benefits and optimal outcomes for patients. Infection rates decreased, and the importance of following the new practices and protocols became apparent to staff. Time and communication were key aspects for success in this step.6 Regular communication was utilized through huddles, staff meetings, newsletters, and email to reach all members of the department and healthcare team.6
- The third step, refreezing, happens when changes are embraced by the healthcare staff. At this point, changes in practice are ready to stabilize the new equilibrium on a healthcare unit or facility. If this step is omitted, the changes may be short-lived and unsustainable as individuals revert to old behaviors.6
Change became a journey toward excellence; perfection was never the goal. Excellence can be met, but perfection cannot be obtained while working with humans and that can be difficult to fully comprehend. The leadership team supported, mentored, and partnered with the frontline staff to navigate the challenges of implementation. Their message was always to follow guidelines, but “Don't let perfect get in the way.”
Success and sustainability begin when individuals and groups realize that transitions take time. Fear, confusion, and ambiguity are natural. When healthcare professionals remember the why of these changes and strong leaders communicate and educate based on evidence and reasoning, however, success and sustainability are attainable.8
It was important for the leadership team to understand past culture to change staff attitudes and focus on the must haves that were required for the new culture. An effective plan showed the team how things would change and focused on the role of individual healthcare professionals more than the final outcome and goal of zero cross-transmissions. Staff buy-in became more apparent as the unit began to see a decrease in the number of affected patients and an increase in infection prevention compliance.8
Sustainability has been maintained for over a year as of this writing. No cross-transmissions have been identified since the implementation of and continued focus on the infection prevention initiatives. The leadership team has refocused on opportunities that have been changed or highlighted through rounding, surveillance, and regular communication. For example, as change in one area becomes hardwired, such as using hand gel before donning and after doffing gloves, the focus may change to another infection prevention task in need of improvement.
Adapting tools based on opportunities and behaviors with continual assessment of processes is essential to maintaining success. As such, the surveillance tool has been modified and the observation focus changed throughout the process. The basics of infection prevention were crucial, and a focus on technique had a major impact on eliminating infections. There were no new infections in a period of more than a year between the implementation of the new processes and the authors' departure from the organization.
The journey toward excellence never ends. Leadership must remain present and engaged, and staff must be supported. Practices must evolve to stay current and demonstrate continuous process improvement. Patient safety should always be the top priority and developed and adjusted according to the PDSA cycle. Success was achieved once the why was understood and the culture changed according to the overall goals of improved patient safety.
The following elements were incorporated as part of the new infection prevention practices:
- Strong administrative leadership: The leadership team partnered with the frontline staff and the medical team to create a vision of excellence. They identified risks and opportunities and developed processes to improve outcomes.
- Effective oversight structure: The infection prevention steering committee provided a venue for decision-making and data discussion. It was also in charge of all planning for potential outbreaks.
- Physician involvement and accountability: The medical director was highly involved in the implementation of the protocols and held the staff accountable for the new processes. Physicians were part of surveillance observations and coached if they were not following the infection prevention guidelines.
- Effective use of information resources: Using data for decision-making was crucial, and surveillance was completed using observation and the electronic health record.
- Effective communication strategies: Data were continually shared through huddles, newsletters, staff meetings, and dissemination at different stakeholder meetings. This allowed for a better understanding of the department's performance metrics.