Patient harm resulting from health care has been a prominent focus for over 15 years, but reducing such harm has been slow and difficult. One success story during this time period has been the 80% reduction in central line-associated bloodstream infections (CLABSIs) across the United States. Although this improvement is often attributed to the use of a central line insertion checklist, the reasons for the plummeting CLABSI rates are complex and are related to the link between traditional biomedical research and improvement science.
Let’s start by differentiating between the two concepts. Biomedical research generally “feeds forward,” starting with a hypothesis of whether one therapy is better than another and then testing the hypothesis by building a corpus of knowledge about the mechanism of disease and the effectiveness of the therapies. In contrast, improvement science “feeds backward,” starting with the goal, drawing upon theory, and then designing a multifaceted intervention to achieve the goal. In other words, biomedical research focuses on solving puzzles whereas improvement science focuses on solving problems. When biomedical research has sufficiently matured the science and evidence pertaining to a particular problem (e.g., CLABSIs), improvement science can design, apply, and evaluate a package of interventions to achieve the desired goal (e.g., reducing or eliminating these infections).
Investing in Biomedical Research
Investment in biomedical research made the improvement in the rate of CLABSIs possible. Starting in the 1970s, the Centers for Disease Control and Prevention (CDC) established evidence-based definitions, developed a valid and reliable measure of bloodstream infection, standardized the data collection process, and created a common measurement system (the National Healthcare Safety Network).
A common measurement and surveillance system made comparability across hospitals feasible and national benchmarking possible by organizing all stakeholders (e.g., researchers, policymakers, consumers, providers, and quality measurement groups) around a common goal and purpose.
The investment of federal and nonfederal funds in biomedical research supported rigorous study of the biology, causes, prevention, and treatment of these infections. Specifically, the National Institutes of Health and the CDC examined the pathogenesis of CLABSIs, investigated the causes of infection outbreaks, revised the clinical practice guidelines, and outlined strategies to reduce these infections.
The Role of Improvement Science
While the role of biomedical research is to solve puzzles by increasing the understanding of disease biology, the role of improvement science (also called translational research or implementation science) is to solve problems by drawing on social science theory in order to help translate evidence into practice. In fact, some of the greatest breakthroughs throughout history, from the 19th-century discoveries by Louis Pasteur to more recent developments at Bell Labs, have been accomplished by linking basic and applied research. Without this link, and a concerted effort to integrate evidence into practice, groundbreaking biomedical discoveries can take years to reach clinicians and patients.
Translating evidence-based strategies for the prevention of CLABSIs to the frontlines of care required an evaluation period. Two large-scale collaboratives in Pittsburgh and throughout Michigan were funded to test the feasibility of implementing the practice recommendations (in checklist format) within diverse intensive care units (ICUs) and to evaluate any associations with reductions in the rate of CLABSIs. Then, a cluster-randomized trial comparing an intervention group with a control group was performed to more strongly correlate the effectiveness of the evidence-based practice interventions in decreasing the rate of infections. The collaboratives demonstrated a 66% to 68% relative reduction in infection rates, and the trial demonstrated a 70% reduction in the intervention group (compared with only a 21% reduction in the control group).
Applying Improvement Science Locally
While these organized studies were successful, it was essential to engage local stakeholders in applying the CLABSI checklist in a manner that fit their local context, thereby motivating them to own the problem and the solution. In hospitals that were ultimately successful in decreasing and sustaining low infection rates, a clearly communicated organization-wide commitment to eliminate infections was backed by structured support from hospital and local ICU leaders to implement the checklist, to monitor and transparently report on performance, and to be accountable for infection rates. For example, if infection rates in an ICU were high for two consecutive quarters, a peer-to-peer review was conducted to uncover the problem and to work with unit managers, department directors, and hospital leaders to develop an improvement plan.
A coordinating team, comprising clinical quality staff and infection control practitioners from the hospital as well as ICU physician and nurse leaders, coached frontline clinicians on the technical components of improvement science (e.g., interventions to prevent infections, data collection procedures, etc.) and supported implementation of the CLABSI checklist. A network of unit-based improvement teams used the comprehensive unit-based safety program to stimulate a culture focused daily on safety and quality improvement. All teams connected as a community to learn and share successes and barriers. The individual team members were instrumental in transitioning the CLABSI interventions into daily practice, educating colleagues about infections, reporting infection rates, and intrinsically motivating coworkers to improve performance.
Underlying Motivations for Improvement
While biomedical research and improvement science were essential in decreasing the rate of CLABSIs, equally important were the underlying motivations of the managers and frontline clinicians who were directly involved in the improvement effort. An ethnographic inquiry of one group of clinicians from different ICUs in Michigan revealed an important discovery, namely, a shift in norms and a change in the narrative from “These infections are inevitable” to “These infections are preventable, and I can help to eliminate them.”
For example, a nurse in a rural Michigan hospital challenged a senior physician who had not donned a sterile gown when preparing to insert a central line, saying, “Bloodstream infections are preventable, and it’s my job to ensure that they are, so go back and put on a gown.”
In addition, when frontline staff listened to and told stories about patients who had been harmed and looked at the faces of those who had died of bloodstream infections, the problem became more personal and real. Similarly, when staff observed the infection rates dropping after the implementation of the intervention at their own hospital or at other hospitals, they understood that such infections were preventable and that they had a role in preventing them.
Aligning National Support for Improvement Science
To help ensure that these discoveries found their way into routine patient care, policymakers aligned the nation around the common goal and sparked a movement to reduce CLABSIs. The Department of Health and Human Services collaborated with patient and professional stakeholder organizations to set realistic goals and launched the National Action Plan to Prevent Health Care-Associated Infections (HAI Action Plan) in 2009. Patient advocacy groups pressured hospital leaders to reduce bloodstream infections and to transparently report their infection rates, which in turn prompted additional state and federal policy initiatives, including a national goal to reduce CLABSIs by 50% between 2009 and 2013. Congress created an incentive to prevent CLABSIs by including the HAI Action Plan in the Affordable Care Act, and the Centers for Medicare & Medicaid Services started publicly reporting CLABSI rates through their Hospital Compare website.
Improvement science encompasses more than a local improvement project; it is a comprehensive approach that draws on social science theory to produce and implement multifaceted interventions for the purpose of accelerating the translation of biomedical research into practice. It brings policymakers and clinicians together, aligning all parties around a common purpose and coordinating efforts at national, organizational, local, and sociocultural levels to achieve a goal. Linking improvement science to biomedical research makes it possible for those in health care to both think like engineers to solve problems and think like biomedical researchers to solve puzzles. While extrinsic motivators such as pay for performance and public reporting can help to engage hospital leaders, intrinsic motivators such as the faces of patients who have been harmed and the belief among clinicians that they can prevent harm will accelerate improvement. In the end, change progresses at the speed of trust, and policymakers and clinicians must create mutually respectful relationships that assume positive intent and are guided by shared leadership accountability.
This article originally appeared in NEJM Catalyst on January 11, 2017.