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Organizational Problem
Context
Healthcare-associated infections (HAIs) are a considerable bother for the US healthcare system. Eisenhower Health Center aimed at reducing the number of HAIs infections by the end of the year by 50% from the level of 2015 (California Department of Public Health, 2019). In particular, the organization has met its goal only in terms of vancomycin-resistant enterococcus bloodstream infections, while other HAIs rates remain high (California Department of Public Health, 2019).
Associated Organizational Challenges
Centers for Medicare and Medicaid have created a series of measures to create financial incentives and disincentives to reduce the number of HAIs. The majority of HAIs cases are not reimbursed by insurers, which is associated with budgetary problems. Healthcare organizations are forced to cover additional inpatient days and treatment costs (Kaier et al., 2020). Additionally, healthcare organizations may be held responsible for preventable harm according to state laws (Kaier et al., 2020). Courts may also compensate victims of actions or inactions that led to the development of HAIs. Such legal liabilities also create budgetary problems.
Evidence-Based Support
Data
HAIs are associated with significant problems for healthcare organizations. On the one hand, the problem significantly increases morbidity and mortality among inpatients. According to Barrasa-Villar et al. (2017), more than 2 million US patients suffer from HAIs annually, and around 25 thousand patients die from them. Thus, it can be concluded that HAIs decrease the quality of care in healthcare organizations. On the other hand, HAIs are associated with increased costs of care. According to Kaier et al. (2020), HAIs are associated with 10-15 percent of additional treatment costs, which are not reimbursed by the insurers. Thus, the issue of increased HAIs in healthcare facilities needs to be addressed to improve the quality of care and reduce costs.
Previous Attempts to Address the Problem
Eisenhower Health implemented several measures to decrease HAI prevalence. First, it adopted a comprehensive hand hygiene practice, which is a crucial measure, according to the Agency of Healthcare Research and Quality (AHRQ, n.d.). In particular, the organization provided on-the-job training to improve adherence to hand hygiene standards. Second, Eisenhower Health Center provided training to nurses concerning full-barrier precautions during central venous catheter insertion, which is one of the central measures for preventing CLABSIs (AHRQ, n.d.). Finally, the organization dedicated significant resources to improve the mindful use of antibiotics, which resulted in a 75% decrease in the occurrence of vancomycin-resistant enterococcus bloodstream infections.
Standards
Currently, there are no regulatory requirements set by the government about the number of HAIs acceptable for a healthcare organization (Kaier et al., 2020). However, the government created incentives that provide quality improvement payments to healthcare organizations. Among disincentives, there are penalties for underreporting HAI cases (Kaier et al., 2020). However, there are standards concerning hand hygiene provided by the World Health Organization, which encourages care providers to wash their hands in five cases: before touching the patient, before aseptic procedures, after body fluid exposure, after touching a patient, and after touching the patient surroundings (World Health Organization, n.d.).
Performance Improvement Initiative
Proposition
Eisenhower Health Center made significant investments in the improvement of hand hygiene using the latest evidence. In particular, according to Mitchell (2017), on-the-job training interventions are expected to improve adherence to hand hygiene standards among front-line personnel. However, after implementing the education proposed by Mitchel (2017), the improvements were insufficient to reach a 50% reduction in the occurrence of HAIs compared with 2015. The reason for the limited impact of the intervention on quality improvement is the lack of a systematic approach to the problem. In particular, the orchestrators of the intervention failed to recognize the complexity of the problem. Thus, a systematic quality improvement intervention concerning adherence to hand hygiene standards is needed to address the identified problem.
The present paper proposes to use a framework provided by the World Health Organization (WHO, 2012) that includes six steps to achieving significant improvements in the area. First, WHO (2012) suggests that the change should be systematic, which includes an assessment of acceptability and tolerability of alcohol-based hand rubs (ABHRs), ensuring the availability of multiple types of dispensers, and engaging with experts to make a cost-benefit analysis (WHO, 2012). Second, the organization should provide additional training and education to care providers, as well as align the knowledge with internal protocols (WHO, 2012). Third, the organization should conduct regular monitoring and compile feedback reports for senior management (WHO, 2012).
Fourth, Eisenhower Health Center needs to put workplace reminders refreshed overtime to help the care provider remember the importance of health hygiene (WHO, 2012). Fifth, senior management needs to make considerable efforts to create a safe climate. This is associated with a multimodal approach, promotion of improvement, engagement of patients, allocation of needed resources, and including adherence to hand hygiene standards into annual goals (WHO, 2012). Finally, the organization should make sure that leaders take additional actions to disseminate knowledge and allocate resources to review and renew the current practices (WHO, 2012). These six steps ensure that all stakeholders are involved in the systematic quality improvement process.
Determinants of Success
The framework provided by WHO acknowledges five determinants of a successful quality improvement program and hand hygiene. These five determinants are described in the self-assessment framework that includes 27 indicators (WHO, 2012). The first determinant is system change, which includes the assessment of sink-to-bed ratio, availability of ABHRs, soap, and paper towels, supply of clean running water, and availability of needed resources to renew the supply of hand hygiene products (WHO, 2012). The second determinant is dedicated to training and education (WHO, 2012). It assesses workers hand hygiene-related training in the facility, availability of required documents about hand hygiene standards, as well as availability of highly qualified trainers and observers (WHO, 2012).
The third determinant is dedicated to evaluation and feedback and includes regular ward-based audits, assessments of care providers knowledge, indirect and indirect monitoring of hand hygiene compliance, and provision of feedback to care providers and upper management (WHO, 2012). The fourth measure for determining success concerns reminders in the workplace. It includes an assessment of the availability of posters and leaflets in all the required places in the facilities (WHO, 2012). The frequency of the reminders renewals and allocation of resources to the aspect is also examined (WHO, 2012). The final determinant is the questionnaire concerning safety climate for hand hygiene. The questionnaire assesses the dedication of team members to hand hygiene and the availability of a clear plan to promote hand hygiene in the future (WHO, 2012). The 27 indicators are assessed using a scoring system, with 500 points being the maximum. Every organization with a score above 375 is considered advanced in hand hygiene standards.
Implementation
Communication Channels
Interdepartmental communication is of extreme importance to the implantation process of the quality improvement initiative. According to Dewitt (2017), efficient communication is associated with an adequate flow of information between relevant stakeholders. Adequate communication helps to avoid mistakes and create an atmosphere of trust, which will lead to improved service provision and increased customer satisfaction (Dewitt, 2017). When speaking about quality improvement projects, communication helps to optimize all the processes to achieve the ultimate goal in the shortest possible time.
The proposed quality improvement project will utilize a wide variety of communication channels. The emphasis on formal and informal communication will be put on digital channels, such as email, messengers (Slack, WhatsApp, and or Viber), online conference software (Skype and Zoom), and social media. The kick-off meeting will be in a face-to-face format, where stakeholders will decide upon the preferred means, frequency, and format of communication. However, the project supposes that there will be at least two face-to-face meetings and two online conferences every year. Additionally, the project manager will submit a report concerning the progress and results every month. The report will also be converted to PowerPoint presentations adapted for different types of stakeholders. The PPTs will be distributed by email every month as well.
Data Interpretation
The quality improvement project supposes that the stakeholders will use both qualitative and quantitative data from different sources. All the data will be acquired based on the principles of WHOs self-assessment framework, which requires information about 27 variables. The data acquired data will be converted into a score between 0 and 500 measured by the questionnaire described in Section 3 of the present paper. The score will be interpreted in several ways. First, the raw score will be provided with a short explanation (0-125 inadequate hand hygiene practices; 126-250 basic hand hygiene practices; 251-375 intermediate hand hygiene practices; 376-500 advanced hand hygiene practices). Second, the stakeholders will be provided with a comparison to other organizations using the same framework and historical analysis of changes in the score. Finally, the data will be interpreted using statistical methods to make predictions of the achievements of the quality improvement initiative. All the data will be compiled into monthly reports and PPTs and distributed among the stakeholders via email. The same data will be used to interpret the progress of the project for stakeholders during bi-annual meetings, face-to-face, and online conferences.
Effect on Patient Care
The initiative is expected to have a significant effect on patient care. The primary effect of the hand hygiene quality improvement initiative is expected to be on the number of HAI cases in Eisenhower Health. If the program is implemented successfully, the HAI occurrence is expected to be reduced by 50% in comparison with the level of 2015 by 2022. This implies that the average length of hospital stay, together with morbidity and mortality, will be reduced significantly (Barrasa-Villar et al., 2017). Thus, the initiative is expected to have a direct effect on improving patient outcomes by preventing HAIs.
However, the project is also expected to have an indirect effect on patient outcomes. In particular, decreased hospital stay of patients will increase the availability of beds in Eisenhower Health Center (Barrasa-Villar et al., 2017. This will enable the personnel to care for more patients if required. Additionally, a decreased number of patient days will reduce the workload of the care providers, which will improve job satisfaction and retention rates. However, while the indirect effect is expected, it will be difficult to measure it.
Health information systems will help the project to achieve the goal, which will eventually benefit the patients. In particular, health information systems will help to collect and interpret the data about adherence to hand hygiene standards. Moreover, health information systems are expected to facilitate the implementation of the project by providing the means of communication between stakeholders.
Effect on the Culture of Safety
The project will have a direct and significant effect on the culture of safety in Eisenhower Health Center. According to the Agency for Healthcare Research and Quality (AHRQ, 2019), a culture of safety is associated with acknowledgment of the high-risk nature of an organization, a blame-free environment, encouragement of collaboration, and commitment of resources to safety concerns. The quality improvement project described in the present paper will improve the culture of safety in the organization by creating additional patterns for interdepartmental collaborations. The experience of communicating during the implementation of the project will help stakeholders discover functional collaboration patterns and use them for everyday tasks. At the same time, it will help the upper management realize that a culture of safety can be implemented only if sufficient resources are provided. Thus, implementation of the project will be a significant step towards the Culture of Safety in Eisenhower Health Center.
Financial Success
The financial implications of the initiative are expected to be significant even though they will not be seen without the analysis of data. Recent research suggests that HAIs are associated with an additional 10-15% increase in costs per patient (Kaier et al., 2020). However, preventing 1 HAI is associated with $25,008 additional costs, which implies that preventing HAIs is a costly initiative (Shepard et al., 2020). At the same time, Shepard et al. (2020) suggest that hospitals can admit 4.62 patients for every prevented case of HAI, which is associated with a profit of $582,464 per case (Shepard et al., 2020). This number also includes costs associated with settling claims against Eisenhower medical center and services that were not reimbursed due to policies of insurers. The total financial implications of the project will depend upon the total number of prevented HAI cases.
Information Management Systems
As mentioned in Section 4, information management systems will contribute to the distribution of data among stakeholders. Additionally, they will help to keep track of the success of the project by providing means for collecting and analyzing data about compliance with hand hygiene policy and changes in HAI occurrence. Timely acquisition of relevant information will help to assess current practices and change them if needed. Thus, information management systems are a vital part of the project implementation strategy.
Organizational Processes
If the quality improvement initiative is a success, several organizational processes will permit the continued viability of the performance improvement initiative. On the one hand, benchmarking will help to sustain the results of the initiative. In simple terms, benchmarking is a continuous comparison of current practices in an organization with those considered the best in the industry. In other words, after the quality improvement project is finished, Eisenhower Health can compare its hand hygiene practices with top-rated hospitals and make improvements if necessary. On the other hand, the organization chooses to follow the principles of evidence-based practice. This implies that authorities can review the latest evidence concerning hand hygiene practices and translate evidence into practice.
Interdepartmental Communication
To sustain the changes achieved during the implementation of the project, the Eisenhower Health Center will need to maintain an adequate level of interdepartmental communication about hand hygiene practices. This may include mailing monthly reports about adherence to hand hygiene practices to relevant departments and discussing the results on corporate forums (such as BaseCamp). Additionally, a separate corporate chat may be created in Viber or WhatsApp to help the stakeholders react to emergencies. These types of communication are expected to be enough to preserve high rates of adherence to hand hygiene standards achieved as a result of the quality improvement program.
References
Hibbert, P., Saeed, F., Taylor, N., Clay-Williams, R., Winata, T., Clay, C.,& & Braithwaite, J. (2020). Can benchmarking Australian hospitals for quality identify and improve high and low performers? Disseminating research findings for hospitals. International Journal for Quality in Health Care, 32(Supplement_1), 84-88.
Kaier, K., Wolkewitz, M., Hehn, P., Mutters, N. T., & Heister, T. (2020). The impact of hospital-acquired infections on the patient-level reimbursement-cost relationship in a DRG-based hospital payment system. International Journal of Health Economics and Management, 20(1), 1-11.
Shepard, J., Frederick, J., Wong, F., Madison, S., Tompkins, L., & Hadhazy, E. (2020). Could the prevention of health careassociated infections increase hospital costs? The financial impact of healthcare-associated infections from a hospital management perspective. American Journal of Infection Control, 48(3), 255-260.
Agency of Healthcare Research and Quality. (2019). Culture of safety. AHRQ.
Barrasa-Villar, J. I., Aibar-Remón, C., Prieto-Andrés, P., Mareca-Doñate, R., & Moliner-Lahoz, J. (2017). Impact on morbidity, mortality, and length of stay of hospital-acquired infections by resistant microorganisms. Clinical Infectious Diseases, 65(4), 644-652.
Dewitt, K. (2017). How to improve interdepartmental communication. Patriot.
Mitchell, A. (2017). Hand hygiene: A quality improvement project. Biomedical Journal of Scientific & Technical Research, 1(7). Web.
World Health Organization. (2010). Hand hygiene self-assessment framework 2010. Web.
World Health Organization. (2012). Your action plan for hand hygiene improvement. Web.
Agency of Healthcare Research and Quality. (n.d.). Guidelines to prevent central line-associated blood stream infections. AHRQ.
Barrasa-Villar, J. I., Aibar-Remón, C., Prieto-Andrés, P., Mareca-Doñate, R., & Moliner-Lahoz, J. (2017). Impact on morbidity, mortality, and length of stay of hospital-acquired infections by resistant microorganisms. Clinical Infectious Diseases, 65(4), 644-652.
California Department of Public Health. (2019). Healthcare associated infections report: Eisenhower Medical Center.
Kaier, K., Wolkewitz, M., Hehn, P., Mutters, N. T., & Heister, T. (2020). The impact of hospital-acquired infections on the patient-level reimbursement-cost relationship in a DRG-based hospital payment system. International Journal of Health Economics and Management, 20(1), 1-11.
World Health Organization. (n.d.). Hand hygiene: Why, how & when? Web.
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