Form 3 Attachment C ICU Site Visit

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI

Appendix C. ICU Site Visit Guidance

Site visits are an opportunity for State Leads and Clinical Mentors to meet with ICU teams and their leadership to strengthen relationships, engage in open discussion about infection prevention and facilitate unit-specific changes through action planning. An early in-person visit can go far to establish relationships with these hospitals and units and open channels of communication which will be needed throughout the project.

This document provides recommendations for planning, conducting and following up on site visits.

1. Planning a Site Visit

1. Identify ICUs to Visit

The State Lead and Clinical Mentors should jointly identify potential ICUs to visit. Priority should be given to those facilities with consistently high rates of CAUTI and/or CLABSI infections, which signal the need for more attention and support from State Leads, Clinical Mentors, and/or the NPT.

In addition, the selection should also consider whether ICUs:

• Have indicated there are challenges with the technical and/or socio-adaptive interventions

• Have requested and expressed interest in a site visit

• Have indicated they have effective practices to share

• Have demonstrated measurable improvement in CAUTI/CLABSI rates

Prior to confirming the site visit, ensure the ICU has submitted its ICU Assessment AND Action Plan, in CDS. This assessment and plan must be completed by the ICU before a site visit is scheduled.

2. Review Data Prior to Visit

Reviewing the data specific to the ICU will provide greater understanding of specific strengths and gaps which can be discussed during the site visit.

• Review the ICU Assessment submitted in CDS

  • Take note of which strengths and barriers the ICU has identified, as well as whether the unit has identified a CAUTI and/or CLABSI champion

• Review the ICU Action Plan as submitted in CDS

  • Review the gap(s) identified by the ICU, as well as the reason

  • Assess the desired aim, strengths and improvement steps recorded. Assess whether there are gaps in the information submitted, which should be discussed at the site visit.

• Review CLABSI/CAUTI data

• Review rates across time

  • Review the unit’s most current SIR and CAD data which led to the unit’s identification for the project

  • Review the unit’s most current Standardized Utilization Ratios/device utilization ratios

3. Review CUSP principles (e.g. Science of Safety, Senior Leadership Engagement and forming a team) to help you develop questions and provide coaching and resources as appropriate during your visit.

• AHRQ CUSP Toolkit

4. Schedule the Visit

Contact the ICU Team Lead and explain the purpose of the site visit. Ensure that the appropriate ICU and hospital staff are available (see sample agenda below). Print out paper copies of the ICU Assessment results from CDS to guide the discussion and action planning.

To facilitate a productive visit, email a copy of the site visit agenda, including names and titles of all who will be in attendance. Ask the hospital to pull these reports from CDS and NHSN and review ahead of time and have with them during the visit:

• ICU Assessment for each unit (CDS)

• ICU Action Plan (CDS)

• CAUTI and CLABSI data from NHSN for each unit (CDS and/or NHSN)

Unit / hospital team members should include the staff most knowledgeable about the implementation of the program. At a minimum, required participants should include:

• The ICU Team Leader,

• ICU Unit Manager(s). Because nurse managers are in a position to align the unit’s goals and processes with a culture change framework, they play an integral role in the support of a unit’s performance improvement work. Nurse Managers are the leader of their units and can influence unit culture and ability to embrace change. Nurse Managers support unit performance improvement activities by integrating CUSP principles and tools into unit workflows. Resources to support discussions about Unit Manager roles for this projects may be found at AHRQ CUSP The Role of the Nurse Manager.

• Senior Leader that will be supporting the team (e.g. CMO, CNO or CQO). Engaging a senior executive to partner with a unit will bridge the gap between senior management and frontline providers and will facilitate a system-level perspective on quality and safety challenges that exist at the unit level. The senior executive's participation and engagement in this quality improvement initiative is vital to the success of the project. Resources to support discussions about Senior Leader roles for this project may be found at AHRQ CUSP Engage the Senior Leader

• CAUTI and/or CLABSI champions as identified in the ICU assessment

• Infection Preventionist

Your role and ability to interface with the senior leader and unit manager(s) throughout the project is important, particularly for those hospitals that are struggling to bring rates down.

Other staff may include:

• Front-line staff

• Nurse educator

• Additional Nurse and Physician Champions, Quality Improvement Champion, not identified above

5. Develop a list of questions/discussion items to cover during the visit, based on:

• ICU assessment, ICU action plan, and data review (as covered above)

• Any information you know about the hospital or unit, e.g. HospitalCompare data, culture of safety survey information, information exchanged on previous calls with the hospital, etc.

2. Discussion Questions

The following discussion questions are designed to help guide conversation with the ICU Team in understanding the ICU’s needs and opportunities where you can support the ICU in meeting goal(s) specified in their action plan.

• Describe your unit culture as it relates to a focus on CLABSI and/or CAUTI prevention (e.g. see ICU Assessment questions 8, 9 , 28, 29, 29a).

• What type of culture of safety training do the unit staffs receive?

• Has this unit ever participated in a CUSP program in the past?

• Has your unit had any formal training in communication techniques such as TeamSTEPPS or other kinds of structured communication methods?

• Does the unit perform any type of root cause analysis or defect analysis when there is a harm event?

• Who on your team is responsible for accessing and disseminating the education?

  • How is education being disseminated amongst the rest of the team? How is the team applying the knowledge gained through the education provided? How are audits and competency assessments connected to program education?

• What is the role of the senior leader on this team?

• What is the communication plan between the senior leader and team if senior leader does not attend all team meetings?

• What is the plan for communicating project progress up the chains of command to leadership? Nursing? Medical Staffs?

• As the state lead for this unit, what tools or resources can you recommend to the unit to use to address their gaps? Consider AHRQ CUSP Toolkit, depending on needs.

  • AHRQ CUSP Toolkit Chapter: Assemble the Team

  • AHRQ CUSP Toolkit Chapter: Understand the Science of Safety

  • AHRQ CUSP Engage the Senior Leader

  • AHRQ CUSP The Role of the Nurse Manager

  • AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI (to be linked)

• The CDC Targeted Assessment for Prevention Strategy: CLABSI and CAUTI Resources

• Engage teams in discussion that focuses on solutions and strategies that can help the ICU overcome potential barriers to achieve goals specified in their action plan.

3. Conducting a site visit

1. At least 48 business hours ahead of scheduled visit, contact the Team Lead to confirm the appointment and agenda.

2. Bring with you to the meeting the materials you emailed/recommended the unit to pull:

• Site Visit Agenda (including list of names/titles of everyone who will be present)

• ICU Assessment results for each unit

• ICU Action Plan for each unit

• CAUTI and CLABSI data from NHSN for each unit

Also bring for yourself:

• A copy of the questions you developed as a guide

4. Following up after a site visit

The State Lead is responsible for completing one electronic Site Visit Report in CDS within 10 business days of the visit. Include ways the unit leader might share the ICU team’s success at the state and national level through speaking opportunities, case studies, discussion boards, SLAC calls, VLGs, etc. Send a thank you note to the unit leader and include a reminder of specific action items you discussed at the visit, and how you will work with them over time to improve their unit’s infection rates and safety culture

Let the units/hospital know that the results of the site visit (State Lead Site Visit Report in CDS) will be kept confidential and that no facility-specific information will be released to AHRQ or to the public.

Sample Agenda

Time	Activity	Participants	Resources Shared
30 minutes	Welcome & Introductions Purpose of the Site Visit Relationship building and knowledge sharing Build an understanding of the ICU’s unique strengths and opportunities for improvement Action planning for measurable improvement in infection prevention	State Lead (facilitator) Clinical Mentors Unit/Senior Leaders and Champions Unit Team NPT (if applicable)	Hospital background ICU characteristics
60 minutes	On-Site Observation Opportunity Members of the Core ICU Team demonstrate practices and share resources related to CAUTI and CLABSI prevention.	ICU Team Lead (co-facilitator) State Lead (co-facilitator) Clinical Mentors NPT (if applicable)	ICU Action Plan
75 minutes	ICU’s Program Progress Describe how you believe the project is going What successes would you like to share? Describe any challenges you are having as you implement the project in your unit. Dialogue with the Core ICU Team Review ICU Assessment, ICU Action Plan, unit NHSN data Discuss progress on achieving goals identified in the ICU’s Action Plan Discuss unit’s core strengths and barriers to achieving their project goals Share resources based on the unit’s needs	ICU Team Lead (facilitator) State Lead Clinical Mentors Core ICU Team (RN and MD Champions, front-line staff and Infection Preventionist) NPT (if applicable)	ICU Assessment ICU Action Plan Infection data CUSP resources and/or program educational content
15 minutes	De-brief and Next Steps State Lead will summarize for the team next steps from the action planning worksheets and follow up on any other identified needs. Emphasize that the Site Visit Report will be kept confidential and that no facility-specific information will be released to AHRQ or to the public.	State Lead (facilitator) Clinical Mentors ICU Team NPT (if applicable)

Public reporting burden for this collection of information is estimated to average 240 minutes per response, the estimated time required to complete the site visit. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.