I'd like to offer you a practical example of sustainment so you can understand a little bit more of what I'm talking about. You may know about the famous project, it was conducted in Michigan around central line-associated bloodstream infections. At two years, you can see that they had managed to reduce these bloodstream infections across all of the participating sites, more than a hundred sites down to zero at the median. Which means that half or more of the sites had zero infections in any given month after the intervention. And so, that's great. That's exactly where we'd like to see it go. But, you might be wondering, well, what happened after the two year study period, did they continue this? Or, did it disappear? If it disappears then that means that people would start getting bloodstream infections again, and facing all of the negative results of having received a bloodstream infection, or developed a bloodstream infection while they were in the hospital. And so, we did a study at four years to try to see whether those same ICUs that had participated in the first part of the project were still managing to keep bloodstream infections down. And as you can see, at those several additional time periods that we considered, the median CLABSI rate was still zero. So, the median, of course, means that, again, half or more than half of the sites have zero infections. So, there may have been some movement around at the top of the distribution where some had some infections. But, overall we're still finding a continuation of the success of the project at the level of the average performance, which is great. Well, how did we do that? And so, some of it was in planning for sustainability. So, practices that added sustainability to this Michigan Project included continuing feedback of infection data that the teams perceived as valid. So, they bought into these infection data, and they continued to feed them back to the clinicians, and let them know how they were doing. If suddenly your report on how you're doing disappears, then your performance will start to slide because you don't have any way of knowing that there have been mistakes made, there have been problems, and so on. So, it's really important to continually provide the data on the performance of the intervention even during the sustainability period. In addition in Michigan, they had improvements in safety culture. And we believe that those supported the overall sustainability of the infection prevention protocols and therefore, these low CLABSI rates. There was an unremitting belief and they preventability of bloodstream infection. So, at no time did people start saying, "Oh, these are common, or these are normal, or we're going to run into some infections just as a matter of course." And before they started the project, in general, there was this belief that some infections were going to happen, and that they were somewhat inevitable, and that that was the risk of doing business, or being in a hospital. But, after the project, people began to understand that most of those in infections were in fact preventable, and they continued to believe that over the long term. And that belief is one of the main reasons why they were able to sustain their results. There was good involvement of the senior leaders. They would review the infection data continually even after the main implementation period was over. And so, they continue to show their support and provide teams with the resources that they needed. And that showed that senior leadership was still paying attention. And that meant that there was continued attention to preventing bloodstream infections even though there were other things that they had been asked to work on as well. And there was a shared goal rather than kind of a competition to reduce infection rates. They looked at it as something that they were trying to do together across the entire state, and so, there wasn't any hiding of information from your competitor, there was a lot of sharing and openness, and that was probably also supportive of the sustainment of the overall intervention. So, we found that some of the things that the sites could do early on in their program that supported this long term viability included writing it into policy, including it in training for all their new members, auditing or monitoring how it's going to make sure that that is routine practice. And so, you're not just watching the infection rate data, but you're also going back in and watching people as they insert those central lines, or as they maintain those central lines, and watching to make sure that that still per protocol so that you know you're still going to be producing those good outcomes. Setting up a reliable supply chain is a key piece here. If for example, you were to run out of some important piece for the Central Line placement kit, then it's possible that people would ignore the fact that it wasn't there. And maybe that's something that includes say, the full barrier drape, sorry, the full length drape or if the hat was missing, for example, from the kit, would people make sure to get it every time? Maybe not. So, having a borrowing protocol or an alert system, making sure that the supply chain was continuous is a key piece here to prevent those exceptions and those violations of protocol. There was a general tendency to develop a quarterly review process so that the executive partner could look back over how things were going and continue to pay attention as I mentioned before. We also encouraged the sites to set up learning networks among their peers so that they would have somebody to talk to you as they go forward, and continue to engage with other units around bloodstream infection, what was working well, where they'd run into problems. They could talk to other hospital units about how it's going, and that makes it much more supported by the peer group and gives you a place to go if there's a problem as opposed to having people throw their arms up because it's not working out any more, we don't know what we're doing wrong, and people tend to give up in such a situation. And then finally, we encouraged them to have regular meetings with the infection preventionist, not to have the IPB a rare face on the unit, but rather make sure that they're continually coming around in order again, to provide the support that was needed to maintain it, the infection reductions, and also to talk about maybe new protocols and new efforts that need to be undertaken alongside. We also encouraged that each one of the sites think about how to sustain their CUSP program, which was the cultural side of the intervention around improving teamwork and safety climate generally speaking, and thinking harder about forms and procedures to make communication among different members of the team, the care team go more smoothly. And so, we suggested the following for CUSP sustainability: maintaining the CUSP team. So, it's possible that at the end of their bloodstream infection intervention, they might have said, "Well let's abandon CUSP. What are we going to work on if we aren't working still on bloodstream infections, or we don't need a whole team to sustain our results." And so, we encouraged them to actually hold onto that CUSP team because the CUSP team can talk about the next issue or the new problem. And maybe consider some rotating membership so that it wasn't overly burdensome on specific people. We encouraged them to think about the fact that some of the teams at Johns Hopkins Hospital have been going on for over ten years. So, even though they weren't working on bloodstream infections during that entire time as a sole focus, they found plenty of things to work on and plenty of things to improve within their units. We did suggest that they continually collect the staff safety assessment, which is where you ask questions about what the next problem is going to be, how the next patient might accidentally be harmed, and what shall we do to prevent that from happening. And we wanted them to keep learning from the defects that they saw arising within their process. So, if a problem happens, don't just fix it once, don't fix it in a temporary way because it will be back again, but rather try to think about what systematic approach could be taken to resolve the specific problem so that you can try to prevent it from ever occurring again. We encouraged them to keep their executive, keep the coach that they had participating, and make sure that they don't think of it as a project or an intervention that's over. It's rather a continuing struggle to prevent infections. And so, having all of the same team members involved over the long run, meaning same roles is important. So, making sure that there is somebody to support that CUSP team, a local CUSP coach, somebody who's already done CUSP and can advise new people on how to do it well, and potentially thinking about a hospital wide CUSP team or meeting across all of the different units that were participating in reducing bloodstream infections so that there could be a social aspect added, and that they could provide each other with information and peer support as they all try to work towards that same goal of reducing infections.
