Engaging a team to stop C. diff

A 528-bed acute care hospital reduced C. diff rates by 53% over 2 years.


Where: Rochester General Hospital, a 528-bed acute care hospital in Rochester, N.Y.

The issue: Reducing Clostridium difficile infections with clinician team engagement.

Background

Everyone in health care knows that hospitalization often causes harm to patients. But in Rochester Regional Health System, clinicians are forced to confront that knowledge because they are asked how they are going to harm the next patient and how they could prevent that harm.

“When you ask team members that question, they're a little startled because they automatically say, ‘Well, we're not going to harm anyone,’ and that's where we tie it to the data of all of the ways that, unfortunately, bad things happen, whether it's infections, whether it's falls, whether it's medication errors, you name it,” said Kristin Opett, RN, vice president of the system's Patient Safety Institute.

The question is part of the Comprehensive Unit Safety Program (CUSP), started about 6 years ago at Rochester Regional. CUSP teams—composed of an executive, a physician/clinician champion, a nurse champion, and a coach (an individual in an operational role)—come together to learn about safety science and measure their safety culture as well as quality metrics, patient satisfaction, and team member satisfaction. They then focus on a project to improve those metrics.

One unit at Rochester General Hospital had an unusually high rate of C. difficile, so executive leadership worked with staff members to target the problem, Ms. Opett said.

How it works

In addition to the usual team members, the unit that focused on C. difficile involved environmental services and pharmacy. “Because the choice of how you clean a room, the choice of which antibiotics that you use are all integral in causing cases of C. difficile, as well as preventing cases of C. difficile, so they needed to be at the table,” said Ms. Opett.

The team tackled C. difficile through simple changes. For instance, members played a hand hygiene game using safety pins: Each time someone caught someone else not washing his or her hands, he or she got to steal a pin, and whoever had the most pins at the end of a specified time period won a prize. And CUSP idea boards served as a place where team members could anonymously share their thoughts about problems and improvements.

Another instance was a case of a long-term patient with C. difficile, whose family would bring him food and store it in a refrigerator with all of the other patients' food. The team had a dorm-style refrigerator put in the patient's room so that he had the comforts of home without potentially transmitting C. difficile around the unit.

Results

The CUSP unit reduced its rate of C. difficile by 53%—from 22.2 per 10,000 patient-days in 2011 to 10.5 per 10,000 patient-days in 2013, according to results published in April by the Joint Commission Journal on Quality and Patient Safety. While the unit has not maintained a complete 50% reduction, it has maintained at least a 40% reduction since 2011, Ms. Opett said.

The unit also showed improvement in its teamwork scores and culture survey scores, she said.

Challenges

“I think one of the things that will always remain with me is that one of the nurses got really mad at me. . . . She said, basically, ‘How dare you say that I'm causing C. diff? I'm not doing that,’” Ms. Opett recalled.

Transparency helped with such challenges. “What I think the greatest lesson for that team was is that they have a voice, they can be engaged, and when they see things that are wrong, they have not just a right to speak up, but they have an obligation to speak up,” she said.

Next steps

In the midst of a merger, Rochester Regional is working to define its safety culture as a new health system, and although it has maintained 8 CUSP teams, its current goals are not CUSP-specific, Ms. Opett said. The system now focuses on using “daily safety checks”—huddles in which senior leadership at each site bring all clinical units together for a 10- to 15-minute roll call to discuss any harm or risk events. The checks are in effect at 2 hospitals and 1 long-term care facility, and Rochester Regional hopes to launch them in its other 3 hospitals before the end of the year.

“It gives all of the leaders, including our most senior leadership, a very strong finger on the pulse for 24 hours,” Ms. Opett said.