Infection Control : Using Change Management Principles to Improve Infection Control
July/August 2013
Infection Control
Using Change Management Principles to Improve Infection Control
Change never ends in healthcare. Institutions must constantly adapt to evolving research, regulations, technology, and economic conditions as well as internal crises.
Because change is inevitable, successful organizations prepare for it. They know they must carefully plan the change process so that staff will broadly accept a new protocol, technology, or organizational strategy.
That’s why leaders in healthcare organizations study change management. In this article, we’ll look at two examples of successful change management involving infection control initiatives. The hospitals involved in both cases achieved significant reductions in catheter-related bloodstream infections (CRBSIs). These ultimate accomplishments stemmed from earlier accomplishments in managing change.
Change Management and Infection Control
Change in infection control often involves what change management literature calls a “first order” change: having the organization improve something it already does. Example: increasing compliance with hand washing before inserting an IV line. With first-order changes, there are few reverberations in the wider institution. In contrast, a “second order” change, such as requiring all staff to use a new EHR, creates ripple effects throughout the organization.
In between these extremes are “middle order” changes. An infection-control-related example would be adding daily monitoring of central lines to central line maintenance practices.
Many changes proposed by infection control experts are first and middle order changes. As management challenges, they may not compare to an electronic health record (EHR) project. But arguably they have greater immediacy. For instance, one doctor’s one-time lapse in hand washing could lead to a fatal CRBSI.
It was concern about the dangers of CRBSIs that motivated White Plains Hospital (WPH) in White Plains, N.Y., and Methodist Extended Care Hospital (MECH), a long-term acute care facility in Memphis, Tenn., to implement new (to them) technology.
WPH began using a disinfection cap to address inherent problems in the traditional method nurses use to manually disinfect IV needleless connectors before accessing IV lines. MECH’s change involved switching to a preventively designed IV connector to better protect its vulnerable patient population from CRBSIs. Its previous connector types, although widely used by hospitals, were associated in studies with elevated CRBSI rates—likely because of design flaws addressed by the new connector.
Interestingly, in both cases, the hospitals selected new devices that had so-called “forcing functions”—that is, the devices made it easy for nurses to do the right thing and hard or impossible to do the wrong thing. This turns out to be an under-the-radar approach to change management. As you’ll see, the stories also illustrate several other concepts in change management.
The White Plains Hospital Story
WPH is a community hospital that prioritizes patient safety and staff accountability. These two factors were intertwined in the way the hospital tried to prevent CRBSIs. Chief Nursing Officer (CNO) Leigh Ann McMahon built a nursing staff that had a passion for patients’ welfare, felt it “owned” all central lines, and took each infection as a personal insult. McMahon believed in participatory management, so she also sought the input of front-line nurses for problem solving.
So far, so good. But in January 2010, WPH uncovered high CRBSI rates in its PICC lines. Interviews of nurses led to the discovery that technique variation was common with WPH’s protocol for manually disinfecting connector hubs. Complete noncompliance also occurred at times. Both problems increase CRBSI risk.
The evidence-based manual disinfection protocol used at WPH is recognized by Salgado (2007), Wright (2013), and others for such lapses—because when nurses are pressed for time, they often rush through or skip the technique. This occurs at hospitals nationwide, not just WPH.
So it made little sense for the hospital to just try to do manual disinfection better. Instead, McMahon empowered her director of infection control, Saungi McCalla, to find an engineered solution that would compensate for the method’s problems.
McCalla recommended a disinfection cap, a device that twists onto the hub and remains there between line accesses, keeping the hub bathed in isopropyl alcohol (IPA). Because it is quick and easy to use, it has the forcing function of encouraging compliance. Because it can only be twisted on one way, like a lid on jar, it also eliminates variation via a forcing function. It helped achieve WPH’s goal by protecting the hub against bacterial ingress the entire time it was on the hub—a benefit manual disinfection can’t provide—and by increasing the hub’s contact time with alcohol, which improves disinfection.
The cap was available in two forms: as a standalone device and in a kit that included a flush syringe. McMahon asked nurses for their input, and they suggested the kit, which had yet another forcing function: it improved compliance with cap use because when the nurses used the syringe to flush an IV line, the bright orange cap was there as its own reminder to use it.
McMahon took their advice. After the cap was successfully trialed and approved by the appropriate committees, it was mandated for use on all central lines including PICCs, all peripheral IVs, and all tubing components such as Y-sites, to create a closed system. The change ultimately resulted in a greater-than-70% reduction in CRBSIs.
This story illustrates several aspects of effective healthcare change management:
- Staff better accept change when they feel it is done for the right reasons. Because WPH prioritized patient safety over bottom-line concerns, its requests had credibility. Leadership’s agreement to acquire new technology demonstrated willingness to add upfront expenses to protect patients. An analysis later showed that cap use was saving WPH nearly $600,000/year in CRBSI-related costs. Had cost savings been offered as the justification for the change, however, that might have undermined the initiative since as theorist John Kotter notes, nurses enter the field to save lives, not money.
- Change management theorist William Bridges writes of the importance of properly managing emotional transitions to a changed circumstance. McMahon’s efforts, to hire nurses whose mission was aligned with the hospital’s, created an emotional preference for patient-safety-oriented change instead of emotional resistance to newness.
- McMahon’s participatory management style, including involvement of nurses in the decision to use the kit, also facilitated acceptance of change because nurses had helped choose the change.
- Because using the device was easier and more effective than manual disinfection, nurses could feel more successful at their task, which facilitated change acceptance.
- Change is more easily accepted when there is an appropriate sense of urgency. No nurse would doubt the urgency of preventing dangerous infections.
- Expert Rashid Al-abri (2007) characterizes change management as “unfreezing old behaviors, introducing new ones, and re-freezing them.” The kit helped “freeze” new behaviors.
- Beneficial change sometimes requires leaders to challenge convention. McMahon and McCalla looked beyond manual disinfection, despite its wide acceptance by hospitals.
The MECH Story
As a long-term acute care facility, MECH served a patient population that was especially vulnerable to CRBSIs for multiple reasons, including serious co-morbidities, intravenous nutrition, and long-dwelling central lines. CNO Sandra Hugueley directed her infection preventionist, Debra Lynch, to search the literature for ways to better prevent CRBSIs.
Lynch found that IV connector design was an underrated issue. As Jarvis (2009) and others have documented, positive and negative pressure connectors are associated with high CRBSI rates, probably because of design issues that made the connectors hard to flush and disinfect.
Hugueley and Lynch eventually chose to try a zero fluid displacement connector designed to address the problems with other connector types. The three-year trial of three different IV connector types encompassed a total of 27,500 catheter days.
A split-septum connector had an infection rate of 6.0 per 1,000 catheter days. A negative-pressure mechanical valve showed an infection rate of 3.3 per 1,000 catheter days. The zero fluid displacement connector, by comparison, had an infection rate of 0.5 infections per 1,000 days, a rate far below the other connectors studied and below the national average in ICUs, which has been variously reported by the Joint Commission (2012) between 1.7 and 14.5 per 1,000 catheter days.
One problem: MECH was part of a larger health system that had standardized usage in its facilities of a kind of connector documented to have a higher-than-normal infection rate. Lynch approached Hugueley for help. Citing their research and study findings, Hugueley then worked with MECH’s CEO to overcome that issue, leading to the connector’s implementation.
This example illustrates the following change management successes:
- To overcome the acquisition barrier, Lynch “managed up,” accessing her superior’s ties to health system leaders to solve the problem.
- As at WPH, MECH’s patients-first culture and sense of urgency about CRBSIs created fertile ground for pro-patient change.
- The new connector has forcing functions. It is easy to disinfect and flush clean and otherwise easier than previous connectors to maintain, so nurses haven’t resisted the change. The lower CRBSI rates associated with it reinforce nurses’ acceptance of change.
- Like WPH’s McMahon, Hugueley and Lynch were undeterred by most hospitals’ tolerance of positive and negative connectors. They were guided by evidence, not convention.
If there is one overriding lesson here, it is this: In infection control, changes can be relatively simple to accomplish if undertaken for the “right” reasons. With a combination of a patient safety culture, nurses’ passion for excellent care, and forcing functions, the stars are aligned for success.
Alan Reder is a freelance writer who lives in Elcho, Wisconsin. His previous work includes numerous books and articles on management and healthcare issues. He may be contacted at areder@frontier.com.
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