Methods to Increase Reliability in Quality Improvement Projects.

Although many quality improvement initiatives in health care see early and laudable success, 1 of the greatest challenges is sustaining the gains and avoiding the natural tendency of systems to revert to their original state, function, and outcomes. Reliability science describes a mathematical and systematic framework for understanding the level of reliability of interventions, and therefore the anticipated success and failure rate of both the steps of a process and the cumulative process overall. Successful utilization of this framework, along with the mindful organizing principles of high-reliability organizations, will facilitate ongoing and long-lasting improvement in outcomes. In this article, we describe practical methods to increase the reliability of interventions toward achieving and sustaining improvement goals.

Eliminating Catheter-Associated Urinary Tract Infections in a Pediatric Cardiac ICU.

OBJECTIVES: To eliminate catheter-associated urinary tract infections in a pediatric cardiac ICU. DESIGN: Quality improvement methodology. SETTING: Twenty-five bed cardiac ICU in a quaternary freestanding children's hospital. PATIENTS: All patients with an indwelling urinary catheter admitted to the cardiac ICU. INTERVENTIONS: Catheter-associated urinary tract infection was defined according to National Healthcare Safety Network criteria. Failure modes and effects analysis and Pareto charts were used to determine etiology of process failures. We implemented a team-based multi-interventional approach in 2012 using the Model for Improvement, which included as follows: 1) establish indications for inserting and/or maintaining bladder catheterization, 2) standardization of maintenance care for the indwelling urinary catheters, 3) protocol for management of the leaking urinary catheters, 4) incorporation of urinary catheter days and prompts for removal in daily rounds, and 5) review of all cases of prolonged indwelling urinary catheter use (> 3 d). Process control charts were used to evaluate change. MEASUREMENTS AND MAIN RESULTS: From 2011 to 2018, we showed an early and sustained improvement in catheter-associated urinary tract infection prevention standards compliance from 44% to 96% (52% improvement). These interventions showed a reduction and then elimination of catheter-associated urinary tract infections from January 2012 to the present day, despite fluctuations in total indwelling urinary catheter days. CONCLUSIONS: Utilization of quality improvement methodology allowed us to identify components of care that contributed to catheter-associated urinary tract infections. After addressing these issues, we noted a substantial reduction and then elimination of catheter-associated urinary tract infections in our pediatric cardiac ICU. Widely disseminating these interventions across multiple pediatric hospitals to determine the ability to achieve similar results are important next steps.

Implementation of a multicenter shoulder dystocia injury prevention program.

Although the evidence for supporting the effectiveness of many patient safety practices has increased in recent years, the ability to implement programs to positively impact clinical outcomes across multiple institutions is lagging. Shoulder dystocia simulation has been shown to reduce avoidable patient harm. Neonatal injury from shoulder dystocia contributes to a significant percentage of liability claims. We describe the development and the process of implementation of a shoulder dystocia simulation program across five academic medical centers and their affiliated hospitals united by a common insurance carrier. Key factors in successful roll out of this program included the following: involvement of physician and nursing leadership from each academic medical center; administrative and logistic support from the insurer; development of consensus on curriculum components of the program; conduct of gap and barrier analysis; financial support from insurer to close necessary gaps and mitigate barriers; and creation of dashboards and tracking performance of the program.