Hospitals tackle MRSA with high reliability

Safety coaches monitor hand hygiene

When your board calls for an improvement initiative, it carries some weight. In 2007, VHA Central Atlantic's board "decided it wanted to work together on a clinical quality initiative, and it chose MRSA reduction," says Terri Bowersox, FACHE, director, performance improvement at VHA Central Atlantic. "And we immediately started a data collection process with the members, and once they had a few months of data, the board decided that it wanted to set the goal to reduce hospital-acquired MRSA infections by 80% in three years. And so we've been working on that ever since, and 2010 is actually the last year of the initiative."

Through January, the system was at a 44% reduction. "We have 57 hospitals in the initiative, and so we feel good. Not sure if we'll get to 80%, but we feel good with where we are," Bowersox says. "It's really about CEO and leadership-driven support and they are supporting this through the organization instead of it just being a project that's in the infection control department."

Bowersox says that along the way, CEOs of each hospital helped to overcome barriers, and they assigned an executive champion from within their facility. Collaboration was essential to reducing MRSA rates. "It has to be an organizational issue because some of the most fundamental work around MRSA reduction or any hospital-acquired infection reduction are things like hand hygiene and proper isolation policies and use of personal protective equipment for isolation patients. Those are really organizational issues. They have to be led by the organization, supported. Many of these hospitals have these types of things in their corporate goals so it's looked at all the way up to the board."

She coaches each hospital and talks to them at least once a month. The "basics" are covered — compliance with hand hygiene, isolation procedures, and personal protective equipment guidelines. "Then we start going into what we consider more advanced strategies, which include things like active MRSA surveillance screens. Many of the hospitals are working on using things like CHG baths (chlorhexidine baths) to treat certain populations prior to surgery." They also talk about things such as making sure device bundles for bath and central lines, as well as established checklists, are used.

Working with consultant HPI, Bowersox says she learned the fundamentals of getting to high reliability and high rates of compliance:

• Reduce the work burden for employees.

"What's the burden, and how do we make sure we minimize it as much as possible? For example, for isolation patients, it is quite a burden to every single time you go in that room you're going to have to put a gown on. That is a burden. There is no doubt about it," Bowersox says.

"So how do you make it be less of a burden? Partly by making sure the supplies are always there. So making sure you have a good process to keep it stocked. Making sure that the staff have some say in where these things are going to be stored, what kind of gown they're going to use, that sort of thing."

• Increase risk awareness.

This means education — "a lot of education about why this is so important. Why is it so important to wear the gown? What are we trying to do? It's trying to prevent this transmission from patient to patient or even patient to your staff member, who then maybe will take it home. So how to make it become real to them," she says.

• Use peer-to-peer coaching.

HPI consultant Shannon M. Sayles, RN, MA, says this step can't be reached until you have built a culture of safety. "What's important, at least from our perspective, that gets reflected in this is that this is a very useful strategy, but it's less useful if you aren't clear with people at the outset about what the expectations are and you give them the tools to do that. That's the approach that we take," she says.

The idea behind it is, "I'm going to encourage a coworker to do the right thing and I'm going to discourage them from doing the wrong thing. And we do that at a ratio of five to one. Five positives to one negative. We have this mindset of, I should at the end of the day feel like, 'Boy I've given a lot of positive encouragement; that's the right thing to do, and I don't remember too many of that was the wrong thing to do.' I'm looking constantly for opportunities to encourage coworkers, peers, and a peer is anybody.

"So that is an extremely useful error prevention tool because it helps build the culture. Most organizations teach and expect that of everybody. But the idea with the safety coach is to identify one, two, or three people within the department at the staff level who become partners with the leaders in building that environment of focus on our safety culture, what we're trying to do, how we want to make safety a core value, how we want to build habits in all the people that work in this department around these error prevention tools."

But she cautions that introducing safety coaches before your organization is ready could make the program fall flat on its face. "It's because you don't start a safety coach program until most of the people in the organization have gone through their training. So that's my point. If you just put a safety coach program in, that's probably what it will look like — a safety police program."

Among the hospitals in the program, some use safety coaches. Others use secret shoppers. "Transporters are really good to be secret shoppers because they're everywhere. And even when they're everywhere, they're looking for these things but no one really knows that's what they're looking for. And they are tracking people's compliance on things like hand hygiene and PPE," Bowersox says.

"Rounding to influence" also has led to success. This type of rounding is used to address a singular issue, such as MRSA, and a minute-long script is used. Often, Bowersox says, leaders now will be a part of rounding, but this rounding to influence is more focused.

Beyond helping with buy in, leadership's interaction with the project has helped it have staying power. "It's amazing the competitive nature of the CEOs. They each want to be the best. And I think that has really driven a lot of this performance, because oftentimes hospitals get in projects and they kind of die off or they don't have the results that you unexpected but no one's paying any attention anyway. This is getting so much attention that I think that had a big part of the success, but I also think the other part is we have taken a multi-prong approach. So we do the coaching, we have the organizational structure with the CEO, the executive champion, and the MRSA team leader. We do lots of coaching. We do sharing calls where hospitals that are doing something really good tell the rest of the hospitals what they're doing and we have networking calls. We have a listserv. We have an awards program for people who have been really successful," says Bowersox.

"So I think it's a combination of all the different things. We definitely consider it a multi-prong approach. And certainly the high reliability work we've been doing with HPI is part of that."