[MUSIC] Looking forward, we're going to talk about how our implementation plan worked and how it played out developing a program for a state many states away. And how we were going to keep them engaged throughout this process of quality improvement. What we did was we choose to include them in a lot of our decision making, and we call this our collaborative model. The collaborative model has been successful in some areas for quality improvement, other areas has not. We have found that the more we make the collaborative model unique to the intervention that we're working with, and we provide a lot of examples, and the paper work that they are going to need, and examples of some of the things they need to develop, that has become very successful. And actually, what we call I learning network, because it allows people from all over, from every different hospital, to participate in developing this program. So I think one of the first things that we had to do was develop a CLABSI toolkit. And a little bit later I'm going to walk you through what was included in some of the CLABSI toolkit development. But really what we needed to do to provide adequate information for the 108 hospitals that were participating, and again, 103 actually were able to provide data through the whole thing, was to give them everything that we talked about that we did at the local level and more. So what that means was we gave them all of the evidence that our literature search identified. So everybody had copies of the different articles that we used. We had fast fact sheets because we knew that there were would be some physicians that did not have the time to read all of the articles that we supported. So there was a synopsis of every one of the fast fact sheets, and a synopsis about how each one of those pieces of evidence was able to impact CLABSIs. So whether that was site placement, and how the subclavian line was really the best option at removing line, because if you don't have a line it can't become infected. We had to provide that. And we also had to do a lot of education because instead of working in a large academic hospital that we where use to hear at John Hopkins, we had hospitals that represented across all of Michigan. So we had some rural hospitals, we had community hospitals, we had teaching hospitals, and we had university affiliated hospitals. And their are level of practice was very different, their ability to put together policies and procedures and have some of the support that we have in academic medicine. We really needed to focus on so that they would have some of the same things that we had going into this work. In addition to the fast facts, and the we also made sure that they had protocols, protocols that talked about placing a central line. We made sure that they had protocols on how to maintain the central line. And what we did was provide them the protocols that we had here at Johns Hopkins that were developed using the CDC guidelines. We also had our protocol on how to use a StatLock to keep the central line in place because during the study they said, let's not use sutures, but let's use a StatLock to hold the central line in place. So for everything that came up about maintaining a central line or placing a central line, we provided them not only the evidence but provided our own protocols that we developed here at Johns Hopkins. And they were to be used as an example, not to be implemented solely because Johns Hopkins did it, because we didn't think that would work. But really to be a guideline for that hospital to write a policy and procedure that, in their eyes, was as black and white as possible. No grey areas, we wanted it to be not something that was subject to interpretation. We wanted it to be as black and white as possible based on their local culture. And really that's what we've worked it to do. We also provided them with the CUSP component, so how do you implement the CUSP program? We also provided each one of the CUSP tools that we had. And I think at the time we had at least a dozen CUSP tools, including daily goals, learning from defects, and many other ones. And for those tools, we also provided an opportunity for them to read the articles where we publish that work. So I wrote an article on a morning briefing, how do you have an effective day by seeing the patients that had the most acuity and then moving on from there. We also had a shadowing tool that also was accompanied by an article that had been published in the Joint Commission Journal because it explained how the tool was used. And it also gave them an opportunity to understand that different units within their hospital all impacted the care that was being delivered. Also anything else that came out, vascular access device, how you access them, the appropriate way to draw blood cultures. Which was when you inserted your first needle you had 24 hours after drawing that first blood culture to have a second culture to have a complete set of cultures. And one of the pushbacks that we had was that patients were often hypo-bulimic and it was very difficult to get that second culture. So after you got the first one, according to the CDC guidelines, you still had 24 hours, within that 24 hour period, to go ahead and get that second culture. So those were all the things that went into the CLABSI toolkit, not only how to insert it safely, and the checklist, how to maintain it, but every piece of evidence and every supporting document that we had here at Johns Hopkins that we could provide to them to use to guide their practice. The next thing that we had to do was how you begin to train somebody when you know that you're only going to be on site to have face-to-face meetings a few times a year? Those meetings were imperative to the success of the program, it allowed us to meet the frontline providers, both the physician and nurses to address barriers that they were having. But to get it kicked off we set up immersion calls. And for those first six weeks we talked about an overview of the program, what they were going to be doing. It gave them an opportunity to talk with their senior leaders to get the supplies that they were going to need. And also to understand what this journey, this two year journey from beginning to end, was going to be about. And it was really about implementing the CLABSI framework, the CUSP framework, getting daily goals off the ground, and then addressing the VAP bundle that we developed. So there was ventilator-associated pneumonia bundle that we also developed for them. And we gave them a lot of individual counseling, but we let them finally pick what they wanted to work with first with CLABSI and CUSP being the primary goals, and that's what we really preferred, but depending on how ready they were. And as I said, at the end of these six weeks we actually expected within a month out after we finished the program that they would be ready to begin receiving our coaching calls and begin the implementation of the program. So the next things that we did, the coaching and content calls, I'm going to say content calls for the sake of this. So each one of the content calls went over one area that we were particularly supportive of. So it was an implementation call, there was a maintenance call, there was blood drawing call. There was when and how to access your vascular access device. How you implemented CUSP, the stages of CUSP, how you identified your defects, which was looking at the staff safety assessment. And we recommend that they pass that out in a meeting that they had with their frontline staff, and then collate their results, and then begin to share that with their senior executive. We talked about the roles of the physician champion. We talked about the role of the senior executive. And we talked about what kind of person really should be on the CUSP team. Keeping in mind that this was not a top-down approach, but this was something that was focused on the local level, the frontline providers, so that they could participate. And it really was an opportunity for them to build capacity and patient safety. And it was an opportunity to let them know what resources were out there for them as they moved forward with the program. And the content calls actually extended from about a month after the immersion calls finished. And we allowed for an hour, maybe 25 minutes for content, and then the rest of the time for question and answers. And we really encouraged each one of the teams from the different hospitals to ask questions, share information, how they were successful, what barriers they addressed? And if they could, if they had changed some of the documents we sent them, to go ahead and share those. Because we really wanted this to be a learning network, and we wanted them not to reinvent the wheel if one of the other hospitals had already done the work. So very important, from beginning to end, they knew that we would have this call and that we would be there to support them. And when we weren't there, there was an email address where they could send us questions at any time and there would be faculty and staff that would be there to address any of the issues. And all of this led to how we planned our next face-to-face meeting, where we would go to Michigan and we would meet with them front on and talk about where we were, how we were doing, and some of the things that we needed to address as we continued. The next thing that we decided to do after we have decided all of the evidence that would be provided in the content calls, what were some of the supplemental calls? And the supplemental calls were really for everybody, they were both for physician providers and nurse's providers. And they provided any additional opportunities or lessons that could be learned for the project progress. And some of the supplemental calls had to do with other quality improvements with tricks that we did for implementations science. And then a lot more about how we went about implementing, and how we successfully implemented. And not only just the technical component, but how we could optimize CUSP and how we could be building team behavior with the CUSP program. And the supplemental calls also occurred probably every month as needed. And again, this was an additional time for them to focus on question and answer. So again, we were building momentum and we were developing a learning network where people felt comfortable. Our hope was that not only will they learn to work with us on this, but they would learn to work locally with other local hospitals to build the momentum that we were looking for so that they were doing these things together. And then we had staff training. So I think staff training was probably one of the biggest opportunities that we had. And a lot of what we did locally, we signed up and we took online modules to say that, yes, we had been certified in fire and safety. Or we had been certified in how to handle contaminated needles, those kind of things. But here we were really looking at focus things that the hospital really didn't address, like what was the appropriate way to do the central line dressing. So rather than just have the protocol, we wanted to be able to show them how you do this. The same with line insertion, how you placed a full barrier drape and water tube to get the most out of that step in the CLABSI prevention. And these were available anytime. And I have to say that one of the things that I think was most useful about all of these calles were they were all recorded, they included both a video clip or the slide deck and the presenter. So that at any time, the frontline providers working in those hospitals, were able to access this information and go back. The other thing it allowed them to do was anytime they had somebody new come on board or a new staff member, a new physicians champion, they were able to access what had already been taught, so that they were quickly brought up to speed.
