Adapting Safety & Quality Initiatives Sustainably in an Environment of Competing Priorities

From the 2023 HVPA National Conference

Shirley Bomhoff, Master of Science in Nursing (LSSBB MedStar Health)

MedStar Georgetown University Hospital, a teaching hospital in the District of Columbia (DC), experienced a sharp increase in central line-associated bloodstream infections (CLABSIs) since the start of the Covid-19 pandemic. This trend was seen nationally during this time, as reported by the CDC. To address this challenge, improve health outcomes, and chart a sustainable pathway for other organizations, MedStar developed resilient and agile improvement methodologies, including data and analytics best practices and a change management program.

MedStar aimed to reduce the CLABSI Standard Infection Ratio (SIR) to a Mean Quarterly SIR of 0.41 or less and reducing the overall CLABSI rate of a mean of 0.88 or less at MedStar Georgetown University Hospital and build a sustainable process to continuously improve health outcomes.

To address CLABSI rates, MedStar implemented SMART performance improvement (PI) methodology, combining traditional Lean Six Sigma concepts with high reliability, change management, appropriate data visualization and interpretation, and coaching a continuous process improvement mindset. It was essential to be aware and respectful of competing priorities and staffing constraints. The team kept the implementation timeline short while ensuring the execution of a robust and effective PI methodology and involving the bedside multidisciplinary team without adding administrative burden.

Through this improvement work, MedStar achieved the following results:
MedStar Georgetown University Hospital CLABSI SIR has decreased from 0.884 (Q3FY20 – Q3FY22) to 0.347 (Q14FY22 – Q2FY23) CLABSI Raw Numbers have decreased from a Quarterly Mean of 3.33 to a Quarterly Mean of 1.33
Organization wide CLABSI SIR has decreased from a mean of 0.88 (Q3FY20 – Q3FY22) to 0.34 (Q4FY22 – Q2FY23)
Organization wide CLABSI rate: Results tracking beginning in Q1FY24

Building on its success, MedStar plans to scale the improvement program across the health system to 8 additional hospitals. To support this effort, MedStar is developing a daily management system to track actionable key process indicators to ensure desired outcomes are maintained.

Clinical Implications:
This initiative significantly reduced patient harm caused by a CLABSI. After testing and then implementing improved clinical processes and structures, the hospital has achieved a significant reduction in CLABSI SIR and Rate. The next steps are to spread these improvements across MedStar Health System to 8 additional hospitals.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

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