Checklists and Culture Shifts: Strategies to Reduce Health Care-Associated Infections

Legal and policy approaches can be important tools for achieving healthier communities. Resources from the Healthy People 2020 Law and Health Policy project provide evidence-based information and identify priority areas that can help communities achieve Healthy People objectives and improve health for all.

This Bright Spot tells how Dr. Peter Pronovost has worked to reduce health care-associated infections by instituting checklists and changing the culture in our health care system.

Challenge: In health care, we’ve accepted that harm is inevitable, not preventable

Health care-associated infections (HAIs) are infections that people get while they’re receiving medical care for another condition. Rates of HAIs have decreased over the years but they’re still common.

Just a few decades ago, more people died each year from HAIs from infections caused by catheters than from breast cancer or prostate cancer.^1,2 And early efforts to reduce HAIs were cumbersome, and often weren’t implemented correctly. For example, 2002 guidelines from the Centers for Disease Control and Prevention (CDC)³ to help providers prevent central line-associated bloodstream infections (CLABSIs) had 95 recommendations, and were complicated and hard to use. In a fast-paced health care environment, providers often saw HAIs as inevitable and unavoidable, despite the fact that these infections are preventable.

Dr. Peter Pronovost started his academic career focusing on health care quality improvement research. But he found new inspiration for his work when he met Sorrel King, a mother whose 18-month-old daughter died in Dr. Pronovost’s hospital due to medical errors including CLABSI. When Ms. King asked Dr. Pronovost how she could be sure this wouldn’t happen to her other children, he realized that he didn’t have a good answer. Since then, he has committed his career to eliminating preventable medical errors like CLABSIs through policy and practice.

Strategies: Summarize the evidence and change the narrative

When Dr. Pronovost began working to prevent CLABSIs, he saw huge gaps in policy. CDC had recently released a valid and reliable method for collecting CLABSI data. But providers were comparing their rates to CDC’s benchmark data, which was based on incorrect assumptions and out-of-date policy and practice. In addition, hospitals had no meaningful incentives to tackle this issue. In fact, hospitals made money on post-care complications like CLABSIs due to existing payment and reimbursement policies.⁴

Dr. Pronovost points out that while solutions like the CDC’s CLABSI guidelines were helpful, they weren’t in a usable format for busy providers. So he created a 5-step checklist focused on the most important steps a provider can take to prevent CLABSIs. Intensive care units (ICUs) in Michigan used the checklist along with other innovative techniques, like making all the supplies providers need available in one place so they wouldn’t be tempted to skip a step to save time. After 18 months, CLABSI rates decreased by 66%.⁵ These processes are now used by hospitals throughout the country.⁶

Preventing CLABSIs is a collaborative effort, and one that Dr. Pronovost thinks can be achieved using a fractal management system—a system that repeats the same management structures at different levels to support large and complicated initiatives. In this case, he believes we need action at the federal, state, and local level. And at the local level, Dr. Pronovost says that higher-level staff and lower-level staff need to work together to support peer learning and increase accountability. Implementing this system has helped international health systems achieve 96% compliance with core measures of quality improvement and significantly reduce CLABSIs.⁷

The idea that doctors are the only ones who can prevent medical errors—and that other health care providers can’t hold doctors accountable for following the checklist—compromises the effectiveness of Dr. Pronovost’s checklist and the fractal management system. “We had to humanize the process and make it clear that it’s okay to make a mistake or forget a step. But it’s not okay to put your patient needlessly at risk because of your ego.” Dr. Pronovost highlights the value of empowering nurses to hold doctors accountable, which helps increase checklist compliance and reduce CLABSIs.

Impact: Checklists as a method for national improvement

Dr. Pronovost has worked with many health care facilities to implement checklists, and encouraged partners at the federal, state, and local level to institute checklist policies for providers. Previously, hospitals, state health departments, and federal agencies worked independently, with hospitals implementing policies to reduce HAIs and health departments collecting the data. By connecting with each other, health professionals are able to create management systems that allow hospitals, states, and the federal government to work together and learn from each other.

Perhaps the most important part of introducing standardized checklists is making the checklists flexible so that health care facilities can adapt them to their needs. “There are thousands of checklists that are 98% the same, but the 2% difference is essential,” Dr. Pronovost says. “Everyone thinks their checklist is the best, and that’s what makes it work.”

Looking ahead: Expanding the focus to all preventable medical errors

It’s hard to pick just one success story when talking about reducing CLABSIs. National CLABSI rates are down 80% in the last 15 years⁸ and continue to fall. Dr. Pronovost attributes this success to changing the narrative around preventable HAIs—and empowering providers to reject the status quo that says harm is inevitable.

Despite the success in reducing rates of CLABSIs nationwide, Dr. Pronovost explains that we need to adopt policies and practices that will address all preventable medical harm—for example, by getting national, state, and local partners to measure preventable harms. He notes that we still don’t truly know how many people die from medical errors each year. “We could know, but we haven’t properly allocated our resources. We need a national measurement system for the top causes of preventable harm, and funding for implementation science to eliminate these harms.” Policies can also encourage organizations to use checklists that they can adapt based on the latest evidence for CLABSI prevention.

Dr. Pronovost continues to work to change the culture in the health care system and bring all the key players to the table to reduce preventable medical errors through policy and practice. He encourages health professionals to declare bold goals and remove their egos to change the narrative around improving care. “In order to drive improvement, we must be passionate, humble, and curious—and remember that everyone brings wisdom to drive success.”

About the Law and Health Policy Project

The goal of the Healthy People Law and Health Policy project was to highlight how evidence-based legal and policy interventions and strategies can facilitate progress toward Healthy People 2020 targets by improving community health and well-being. In addition to reports and webinars, the project included "Bright Spots," or success stories, that highlighted successful policy interventions that led to improved health outcomes. The project was a collaboration between the HHS Office of Disease Prevention and Health Promotion (ODPHP), the Centers for Disease Control and Prevention (CDC), the CDC Foundation, and the Robert Wood Johnson Foundation.