HCA Safe Critical Care Initiative
Implementation Plan for Safe Critical Care Project
Progress Report for Central Line Catheter-Related Blood Stream Infections
Date: __________
Instructions: Cut and paste from you Pre-Work Plan or most recent Implementation Plan where and when you can.
Hospital Name:
City, State:
ICU Name:
Project Coordinator
Name:
Phone:
e-mail address:
Aim (What are we trying to accomplish?): To prevent central line catheter-related blood
stream infections and ventilator-associated pneumonia in the ICU.
Team Members (Assemble a team. List the members of your team and update as needed.
Appropriate members include physicians, nurses, managers, infection control personnel,
pharmacy, RT, ICU staff, etc. Who should work on this improvement?):
Name
Title
Role
Project Leader
Physician Leader/Champion
Facilitator
Key CVC-BSI Measures (How will we know if a change is an improvement?):
1.
2.
3.
4.
5.
6.
Required Measures
Outcome: CVC Infection
Hand Hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Subclavian vein for non-tunneled catheters
Daily review of line necessity
Bundled/Composite Score of #2 through #5
Optional Measures
Goal
Goal
7.
8.
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Change Ideas (What changes can we make that will result in an improvement?):
1.
2.
3.
4.
5.
6.
ACTION PLAN
Choose the areas where your team will be making improvements. Briefly describe the overall
goal and plan for achieving it. Iteratively list each new subproject/strategy you initiate and
update as needed. Add objectives.
Change Idea (Project #1): ________
Target or Category (e.g. education, measurement, supplies, work roles, safety culture, ….):
________
Objective (describe goal): ________
What: ________
When: ________
Where: ________
Who: ________
Change Idea (Project #2): ________
Target or Category (e.g. education, measurement, supplies, work roles, safety culture, ….):
________
Objective (describe goal): ________
What: ________
When: ________
Where: ________
Who: ________
Change Idea (Project #3): ________
Target or Category (e.g. education, measurement, supplies, work roles, safety culture, ….):
________
Objective (describe goal): ________
What: ________
When: ________
Where: ________
Who: ________
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PDSA Projects
Each action plan for a change idea (subproject or strategy) will undergo one or more PDSA cycles.
Start a new page and project number (e.g., 1, 2, …) for each target of change. A PDSA cycle is a small
test of change; it is a test of the intervention to see if the implementation will potentially work. Add
iterative PDSA cycles using cut and paste of the word template as needed. Supplement the Project
Report with tables or charts of results. A sample is shown at the end.
Change Idea (Project #1): ________
Target or Category (e.g. education, measurement, supplies, work roles, safety culture, ….):
________
Objective (describe goal): ________
Prediction for the PDSA: ________
Briefly describe your P (Plan), D (Do), S (Study), A(Act ) cycle.
Plan = Describe who, what, where, when, why. How will you measure success with the test?
Do = Describe implementation. Problems? Data collected?
Study = Describe and distribute the results, data analysis –was the test successful?
Act = Describe what you will do with the results; what are the recommendations?
PDSA #1 Start Date: ________
Plan: ________
Do: ________
Study: ________
Act: ________
PDSA #2 Start Date: ________
Plan: ________
Do: ________
Study: ________
Act: ________
PDSA #3 Start Date: ________
Plan: ________
Do: ________
Study: ________
Act: ________
PDSA #4 Start Date: ________
Plan: ________
Do: ________
Study: ________
Act: ________
End Date: ________
Example --- Just put in your own graphs from the Excel Tool
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Change Idea (Project #2): ________
Target or Category (e.g. education, measurement, supplies, work roles, safety culture, ….):
________
Objective (describe goal): ________
Prediction for the PDSA: ________
Briefly describe your P (Plan), D (Do), S (Study), A(Act ) cycle.
Plan = Describe who, what, where, when, why. How will you measure success with the test?
Do = Describe implementation. Problems? Data collected?
Study = Describe and distribute the results, data analysis –was the test successful?
Act = Describe what you will do with the results; what are the recommendations?
PDSA #1 Start Date: ________
Plan: ________
Do: ________
Study: ________
Act: ________
PDSA #2 Start Date: ________
Plan: ________
Do: ________
Study: ________
Act: ________
PDSA #3 Start Date: ________
Plan: ________
Do: ________
Study: ________
Act: ________
PDSA #4 Start Date: ________
Plan: ________
Do: ________
Study: ________
Act: ________
End Date: ________
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Implementation Science: Method for Improvement
The Model for Improvement
What are we trying to accomplish?
How will we know that a change
is an improvement?
What changes can we make that
will result in an improvement?
Act
Plan
Study
Do
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PDSA Cycle: Implementation
PLAN • Hypothesis: What do you expect to accomplish?
•
•
•
•
•
Action Plan: Who? Does What? When?
With what tools and training?
What are the data collection procedures?
DO
How will the change be implemented?
What are the process indicators?
STUDY • What are the results?
• What happened?
• What are we learning?
ACT • Was there success?
• What will we do with the results?
• What else needs to be done?
• Are there more change ideas?
• What do we do to hold the gains ?
What is the PDSA Cycle?
Act
• What changes
are to be made?
• Next cycle?
Study
Plan
• Objective
• Questions and
predictions (why)
• Plan to carry out
the cycle (who,
what, where, when)
Do
• Complete the
• Carry out the plan
analysis of the data • Document problems
• Compare data to
and unexpected
predictions
observations
• Summarize what • Begin analysis
was learned
of the data
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Fast Tracking Cycles of Change;
Slow Track – Single Objective at a Time
Fast Track – Multiple Objectives at same Time
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Tips for Successful Tests of Change
Stay a cycle ahead
 Pick easy changes to try
Scale down the scope of tests
 Avoid technical slowdowns
Pick willing volunteers
 Reflect on the results of every
change
Pick changes that don't require a
lengthy approval process
 Be prepared to end a test of change
Don't reinvent the wheel
 Collect enough data to evaluate the
pilot test
Pilot test implementation ideas
 Learn from experience – if you
Use listserv for ideas
want to learn about a system, try
Team work, team input
to change it
Commitment, motivation and
 Focus on Culture and Task
willingness to change
Reasons the PDSA didn't go as planned
Change was not well executed
 Support was inadequate
Hypothesis/hunch was wrong
 Lack of attention to detail,
breakdown into series of small
Took on too much, too soon
changes
Didn't make implementation part
 Only task oriented
of the day-to-day operation of the
system
 Lack of interest, no sense of
urgency
Quit too soon, didn't work out the
 Blame environment
bugs
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Sample of a Project Action Plan
ACTION PLAN
Choose the areas where your team will be making improvements. Briefly describe the overall
goal and plan for achieving it. Iteratively list each new subproject/strategy you initiate and
update as needed.
Change Idea (Project #3): Clinicians will undergo CVC-BSI CME training
Target or Category (e.g. education, measurement, supplies, work roles, safety culture, ….): CVCBSI education
Objective (describe goal): All staff will have certified CME training on CVC-BSI.
What: All providers who give direct patient care in the ICU will undergo annual training
relevant to central line catheter-related blood stream infections.
When: June 2006
Where: Healthstream CME, HCA WebEX
Who: Ian Adherent RN, ICU Manager
PDSA Projects
Each action plan for a change idea (subproject or strategy) will undergo one or more PDSA cycles.
Start a new page and project number (e.g., 1, 2, …) for each target of change. A PDSA cycle is a small
test of change; it is a test of the intervention to see if the implementation will potentially work. Add
iterative PDSA cycles using cut and paste of the word template as needed. Supplement the Project
Report with tables or charts of results. A sample is shown at the end.
Change Idea (Project #3): Clinicians will undergo CVC-BSI CME training
Target or Category (e.g. education, measurement, supplies, work roles, safety culture, ….): CVCBSI education
Objective (describe goal): All staff will have certified CME training on CVC-BSI.
Prediction for the PDSA: Staff will have greater understanding of the importance of patient
safety and reasons for nursing documentation of the CVC-BSI process measures. Staff will
find the training professional and current.
Briefly describe your P (Plan), D (Do), S (Study), A(Act ) cycle.
Plan = Describe who, what, where, when, why. How will you measure success with the test?
Do = Describe implementation. Problems? Data collected?
Study = Describe and distribute the results, data analysis –was the test successful?
Act = Describe what you will do with the results; what are the recommendations?
PDSA #1 Start Date: March 15, 2006
Plan: Ian Adherent will send an email link for the CVC-BSI CME to the MICU providers requesting
certification with training. Providers will be given 2 weeks starting today. Training rates will be monitored by CME
certification.
Do: Send email. Collect certification. Track training rate. Provide weekly updates at staff meetings on %
staff trained.
Study: Staff trained was 45% week one, and 65% week two. Rate is 70% for nurses and 30% for
physicians.
Act: Physicians need community access to the training, provide a web link. Nag those who have not
completed training. Everyone felt the training was appropriate and professional.
PDSA #2 Start Date: April 1, 2006
Plan: Ian will send a Healthstream web link for the CVC-BSI CME to ICU physicians. All other staff will
receive a written reminder to complete the training within the next two weeks.
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Do: Send email. Track. Compile results.
Study: Training rate is 93%. Seek administrative support from appropriate directors making certified
training mandatory.
Act: Spread training to all the hospital ICUs.
PDSA #3 Start Date: ________
Plan: ________
Do: ________
Study: ________
Act: ________
PDSA #4 Start Date: ________
Plan: ________
Do: ________
Study: ________
Act: ________
End Date: ________
Summary
This toolkit aids your quality improvement process. The tool starts with pre-work organization
that includes team formation, specification of measures, brainstorming change ideas and preliminary
formulation of action plans. The implementation tool iteratively builds on the preliminary action plan.
The project pre-work is imported onto the implementation plan and progress report; ongoing revisions
are added to guide the continuous improvement. The action plans are specified further by adding details
and objectives. Each target area the team selects for improvement is imported into a continuous cycle of
PDSAs. The example shows the planning and updates for two PDSA cycles for the target of clinician
education. In this example, the action plan would continue with formation of PDSA cycle #3 and
continuously recycle until the goal is reached and the target successfully completed or a new target is
formulated.
Thus, this toolkit is available for Quality Improvement strategic planning, implementation and
documentation. Participants in the Safe Critical Care Collaborative will be requested to submit either
this progress report or something similar.
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