Running head: QUALITY IMPROVEMENT PROJECT

Quality Improvement Project

Dahlia Rose
NUR 4144 Professional Role Development:
Servant Leadership
Dr. Ellcessor
October 24, 2016

I pledge.

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Introduction

Central venous catheters (CVCs) are essential devices utilized in the intensive care unit
(ICU), for infusion of medications, fluids, blood products; hemodialysis; lab draws; or
hemodynamic monitoring. Due to the invasive nature of these devices, patients are predisposed
to central line-associated blood stream infections (CLABSIs). (Blot, Bergs, Vogelaers, Blot &
Vandijck, 2014) CLABSIs cause significant morbidity and mortality and costs to the healthcare
institution. According to the Center for Disease Control and Prevention (CDC), an estimated
43,000 CLABSIs occurred among ICU patients in the United States in 2001. However due to
quality improvement efforts, by 2009 there were 25,000 fewer cases of CLABSIs among ICU
patients. (Srinivasan et al., 2011)
The purpose of this paper is discuss quality improvement measures to decrease the
incidence of CLABSIs in the ICU. The quality improvement project will be implemented
utilizing the four domains of leadership (heart, head, hands, and habits) as outlined in the Lead
Like Jesus textbook; and the five practices of exemplary leadership (model the way, inspire a
shared vision, challenge the process, enable others to act, and encourage the heart) as discussed
in class. Lastly, final evaluation will include how this project will affect professional nursing
practice and how it will improve the outcomes of the patients with CVCs in the ICU.
Four Domains of Leadership
Heart
Leadership first begins with the heart. Leaders have the opportunity to influence the
behavior and thoughts of others and it is essential to be motivated by the benefit of those they
serve rather than by self-interest (Blanchard & Hodges, 2005). A servant leader is one who is a
steward for their community and is focused on the good will of others. Therefore, by

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understanding the serious ramifications that CLABSIs have on morbidity and mortality and
associated healthcare costs, a nurse leader has an opportunity to improve patient outcomes on
their unit and ultimately decrease costs for the institution that they represent. The nurse manager
can help establish motivation from their staff by creating awareness of the problem and then
discussing the importance of improving the care provided to patients with CVCs.
Head
Once motivation is achieved through the heart of leadership, the next domain is the head.
In this domain, the leader should envision the course for the future of the unit, establish clear
goals, and then implement them. Rather than dictate those goals, a nurse manager should
empower and support their staff to work as a team to achieve those goals. Knowing that
CLABSIs are a preventable problem within the ICU, the nurse manager should discuss
implementing prevention measures to improve the outcomes of patients with CVCs. The nurse
manager can then establish a timeline for the unit and then offer incentives should they meet
their goals.
Hands
Others will be able to further understand the head and heart of a leader by observing their
actions (hands). A leader should be a mentor and coach for their staff, guiding them and helping
them to foster self-confidence and autonomy in their roles as a nurse. (Blanchard & Hodges,
2005) By allowing them to gain some independence, the leader demonstrates trust and respect
for their abilities. This domain allows the nurse manager to evaluate performance trends.
Performance evaluations is a way to discuss strengths, goals, and opportunities for growth.
Rather than criticizing staff, the nurse manager should give constructive feedback and then

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provide resources if necessary to help them reach their full potential. Performance evaluations
should then help to unify the team and ultimately improve patient outcomes.
Habits
In order to stay on track with his mission, Jesus applied five key habits of: solitude,
prayer, study and application of scripture, accepting and responding to Gods unconditional love,
and involvement in supportive relationships (Blanchard & Hodges, 2005). Adopting these same
five habits should be essential to the role of a servant leader. Implementing any practice change
is no easy feat and therefore as a nurse leader, its important to be still and center oneself prior
to making tough decisions. Once they have allowed time to reflect within themselves, they can
support and guide their staff to continuously advocate for their patients and make sure that they
are working as a team towards their goals to improve outcomes.
Five Practices of Exemplary Leadership
Model the Way
In order to model the way, the leader should set an example for others to follow. With the
shared vision of of improving patient outcomes with regards CLABSIs, the nurse manager
should establish clear goals and strategies for the unit. Prevention measures such as hand
hygiene, maximal sterile barriers during catheter insertion, chlorhexidine skin disinfection,
optimal catheter site selection, and daily review of line necessity with prompt removal of
unnecessary lines, have been known to improve the outcomes of patients with CVCs. (Blot et al.,
2014)
After discussing the measures that would improve patient outcomes regarding CLABSIs,
the nurse manager would then need to implement practices to make sure that their staff clearly
understands their roles in CLABSI prevention and how to best apply it into practice. A nurse

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manager can then establish staff education opportunities and utilize catheter care bundles and
checklists to help decrease CLABSIs and also improve the adherence of these prevention
measures on their unit. (Blot et al., 2014)
Inspire a Shared Vision
Compliance with these already established evidence-based infection control practices
remains a challenge in eliminating CLABSIs (Sacks et al., 2014). Therefore, as a nurse manager
it is even more pertinent to inspire and encourage their staff to comply with the above mentioned
prevention measures. The nurse manager can help combat any resistance to this practice change
by mentioning that through compliance with these prevention practices, there was a 58%
decrease in the incidence of CLABSIs within a span of 8 years. Hence, it is possible to
eventually eradicate the incidence of these infections as long as they remain diligent.
Challenge the Process
While these prevention measures have shown to decrease the incidence of CLABSIs, the
nurse manager should continuously seek innovative ways to improve the process of
implementing this into practice. The Institute for Healthcare Improvement (IHI) developed a
Central Line Bundle and checklist to help facilitate this process. The bundle consists of proper
hygiene, chlorhexidine skin preparation, preferential use of the subclavian vein, maximal barrier
precautions during the insertion process, and a daily assessment of catheter need. (Sacks et al.,
2014) Change takes time to perfect, and therefore the nurse leader can foster open
communication and make changes when necessary.
Enable Others to Act
As a nurse leader, it is important to establish a sense of autonomy and self-confidence
among their staff by trusting and confiding in them to reach their individual goals and those of

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the unit as a whole. This autonomy will not only promote a sense of empowerment but it will
also help to foster collaboration and trust among the team. Additionally, it will allow the staff
room to speak up for what they believe is working, what is not working, and then they can offer
suggestions to help improve the process. For instance, while the IHI central line bundle and
checklist may have been beneficial on other units, it may not work with the flow of this unit. So
then as a team, we can discuss how we can implement something similar that would offer the
same outcomes.
Encourage the Heart
Often times staff can become discouraged when their efforts go unnoticed which will
then transpire into decreased work ethic and will inevitably demoralize the efforts of the team as
a whole. Thus, as a nurse leader it is important to provide recognition when recognition is due.
Also, the nurse leader should inspire a team that builds each other up and motivates each other
towards excellence in practice. One way to motivate the morale of the team is to offer incentives
once goals are met. For example, say the goal for the month is to see at least a 1% decrease in the
rate of CLABSIs and that is met, an incentive can be to offer a catered staff lunch/dinner. By
establishing clear goals and then offering incentives, they will be more encouraged to remain
determined in their efforts to improve patient outcomes.
Professional Practice Implications
CLABSIs are serious but preventable healthcare associated infections (HAIs). Due to
quality improvement efforts, there was an estimated 58% reduction in the incidence of CLABSIs
within a span of eight years among ICUs across the nation. This reduction represents close to
6,000 lives saved and around $414 million dollars in health-care costs in 2009 and approximately
$1.8 billion in cumulative costs since 2001. (Srinivasan et al., 2011) This signifies the

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importance of being meticulous in practice to maintain infection control practices to prevent

further occurrences, improve patient outcomes and decrease costs to the institution.
The Center for Disease Control and Prevention (CDC) suggests that healthcare
professionals utilize their Guidelines for Prevention of Intravascular Catheter-Related Infections
to help reduce the incidence of CLABSIs. They advise that the subclavian should be chosen over
the femoral vein in adult patients. Ultrasound guidance should be used during placement of the
CVC. Transparent dressings should be replaced every 7 days unless it is visibly soiled, loose or
damp. The patient should be washed daily with 2% chlorhexidine. Hand hygiene should be
performed before and after contact with the line. Maximal sterile barrier precautions (sterile
gloves, sterile gown, cap, mask, & large sterile drape) should be used during insertion. Lastly, the
line should only be kept as long as necessary. (Srinivasan et al., 2011) Evidence-based practice
has also shown that utilizing bundles and checklists, such as that by IHI, in the insertion and
maintenance of CVCs has helped to improve the adherence of these infection control practices
(Sacks et al., 2014).
Outcomes Evaluation
In order to evaluate the effectiveness of these quality improvement measures, it is
important to assess the CLABSIs rates within the ICU at the start and then after implementation
of those measures. Patient outcomes are the top priority of the unit, so that would be the first
thing to assess. Next, the nurse leader should assess the staffs response to the use of the bundles
and checklists and the use of prevention control measures in practice. This can be assessed by
offering anonymous surveys among the unit. Additionally, a nurse manager can utilize an
assessment tool such as the CLABSI baseline prevention practices assessment tool offered by the
CDC. The results can be used to measure practice changes, determine the extent of targets being

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met and the effectiveness of outcomes being achieved on a state-wide level (CDC, nd). In
conclusion, a nurse leader should also allow open communication among staff and be available
to provide redirection and guidance when necessary. Through the use of effective collaboration
and open communication we can continue to improve the outcomes for our patients.

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References

Blanchard, K. & Hodges, P. (2005). Lead like Jesus. Nashville, TN: Thomas Nelson.
Blot, K., Bergs, J., Vogelaers, D., Blot, S., & Vandijck, D. (2014). Prevention of
central line-associated bloodstream infections through quality improvement
interventions: A systematic review and meta-analysis. Clinical Infectious Diseases,
59(1), 96-105. doi: 10.1093/cid/ciu239
Center for Disease Control and Prevention. (nd). CLABSI baseline prevention practices
assessment tool for states establishing HAI prevention collaboratives using abra
funds. Retrieved from
http://www.cdc.gov/HAI/recoveryact/PDF/CLABSI_EvalQuestions_Final.pdf
Sacks, G.D., Diggs, B.S., Hadjizacharia, P., Green, D., Salim, A., & Malinoski, D.J. (2014).
Reducing the rate of catheter-associated bloodstream infections in a surgical intensive
care unit using the Institute for Healthcare Improvement central line bundle. The
American Journal of Surgery, 207, 817-823. doi: 10.1016/j.amjsurg.2013.08.041
Srinivasan, A., Wise, M., Bell, M., et al. (2011). Vital signs: Central-line associated blood stream
infections-United States, 2001, 2008, and 2009. Centers for Disease Control and
Prevention Morbidity and Mortality Weekly Report, 60: 1-6.