An Examination of the Barriers to and Facilitators of Implementing Nurse-Driven Protocols to Remove Indwelling Urinary Catheters in Acute Care Hospitals

Abstract

Background:

Urinary catheter nurse-driven protocols (UCNDPs) for removal of indwelling urinary catheters (IUCs) can potentially prevent catheter-associated urinary tract infections (CAUTIs). However, they are used inconsistently. Our objective was to examine the barriers to and facilitators of implementation of UCNDPs in acute care hospitals.

Methods:

Between September 2017 and January 2019, we interviewed 449 frontline staff (i.e., nurses, physicians), managers, and executives from 17 U.S. hospitals to better understand their experiences implementing, using, and overseeing use of UCNDPs. Our semi-structured interview guide included questions about management practices and policies around enactment of a UCNDP.

Results:

Although the features of UCNDPs differed across hospitals, our analysis revealed that hospitals experienced common issues around implementing and consistently using UCNDPs as a result of three major barriers: (1) nurse deference to physicians, (2) physician push-back, and (3) miscommunication about IUC removal. Interviewees also described several important facilitators to help overcome these barriers: (1) training care team members to use the UCNDP, (2) discussing IUC necessity and the opportuning to use the UCNDP during rounds, (3) reminding care team members to follow UCNDPs, and (4) building buy-in for UCNDP use across the hospital.

Conclusion:

Although UCNDPs are fundamental in efforts to reduce and prevent CAUTIs, hospitals can proactively support their implementation and use by developing the skills of care team members need to enact UCNDPs when patients meet the clinical indications for removal, and increasing awareness about the value and importance of such protocols for reducing CAUTIs and improving patient safety.

BACKGROUND

A catheter-associated urinary tract infection (CAUTI) is one of the most common health care–associated infections (HAIs).¹ Approximately 12% to 16% of hospitalized adults will have an indwelling urinary catheter (IUC) (commonly referred to as a Foley catheter) inserted during their stay,² and the risk of acquiring an infection increases each day it remains in place.³ These infections can result in longer hospital stays and higher costs of care.^4,5 Reducing CAUTIs has become an area of focus of the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program, which reduces payments to hospitals in the worst-performing quartiles for HAI measures, including CAUTI incidence.⁶

Evidence-based guidelines give health care providers a framework to maintain, monitor, and properly remove IUCs^3,7–11; however, preventing CAUTIs has proved difficult.^12–15 Urinary catheter nurse-driven protocols (UCNDPs) for removal of IUCs are clinical directives aimed at reducing CAUTIs; they allow nurses to remove these catheters from patients who meet pre-specified clinical indications, with little or no physician consultation.^15–19 A growing body of evidence suggests that UCNDPs can decrease average catheterization time and improve quality of care.^20,21 Yet despite the potential benefits of UCNDPs to reduce CAUTIs, UCNDPs are not used consistently in acute care settings.^22,23 Reported challenges around UCNDP use include patient and family requests to maintain IUC placement, cultural norms around leaving catheters in place, clinical convenience, and the discomfort of nurses who have to enact the UCNDPs.^23–25

Improving our understanding of how hospitals implement UCNDPs is important in the context of HAI prevention and may help identify opportunities to address barriers to protocol use^23,24,26 as well as minimize CAUTIs.²⁷ Using data from a multiyear research project focused on identifying management practices to reduce HAIs,²⁸ we conducted a secondary analysis to examine barriers to and facilitators of UCNDP implementation and use across the 17 hospitals that participated in that study.

METHODS

Study Setting and Participants

Using a purposive sampling approach, we invited 35 acute care hospitals from across the United States to participate in a study that aimed to improve our understanding of management practices that support HAI prevention efforts.²⁸ To ensure variability among participating hospitals, we attempted to recruit both higher- and lower-performing hospitals and include hospitals from different regions and with a variety of organizational characteristics (e.g., hospital size, teaching status). We used standardized infection ratios (SIRs) to define hospital performance on infection prevention. The SIR is a summary statistic that compares the number of observed HAIs in a hospital to the number of predicted HAIs based on a national benchmark. Seventeen hospitals agreed to participate. Table 1 presents a general overview of the characteristics of participating hospitals.

Table 1.

Characteristics of Hospitals Participating in Study (n=17)

Hospital Characteristic	N (%)
Hospital size
< 300 beds	6 (35)
300 – 499 beds	3 (18)
500 – 899 beds	5 (29)
≥ 900 beds	3 (18)
Region
East	5 (29)
West	2 (12)
Midwest	6 (35)
South	4 (24)
Ownership status
Non-profit	14 (82)
Government	2 (12)
Proprietary	1 (6)
Membership in COTH
Yes	10 (59)
No	7 (41)
Safety net hospital *
Yes	5 (29)
No	12 (71)

^*Defined as hospitals in the highest quartile of the disproportionate share hospital index.

COTH, Council of Teaching Hospitals.

Data sources: American Hospital Association Annual Survey; Centers for Medicare and Medicaid Services Hospital Compare.

Data Collection

Our research team conducted site visits to the 17 participating hospitals from September 2017 to January 2019. As part of these site visits, we conducted 449 interviews with a variety of key informants, including executive leaders, managers (including both nonclinical and nurse managers), infection preventionists, and frontline staff (i.e., nurses, physicians). Table 2 summarizes the total number and percentage of interviews by site and interviewee role. The Institutional Review Board of The Ohio State University approved this study and informed consent was obtained.

Table 2.

Numbers and Percentages of Interviewees Participating in Study, by Site and by Role

Site Number	Executives	Managers*	Infection Preventionists	Frontline Staff	Site Total (%)
1	3	21	10	12	46 (10)
2	1	4	2	9	16 (4)
3	3	6	11	10	30 (7)
4	2	4	4	5	15 (3)
5	1	10	7	11	29 (7)
6	4	10	1	11	26 (6)
7	1	12	2	26	41 (9)
8	2	8	5	11	26 (6)
9	7	4	6	10	27 (6)
10	2	3	4	11	20 (5)
11	1	5	4	9	19 (4)
12	2	11	8	11	32 (7)
13	3	7	9	11	30 (7)
14	3	4	5	7	19 (4)
15	7	5	5	10	27 (6)
16	1	5	4	6	16 (4)
17	3	12	9	6	30 (7)
Role Total (%)	46 (10)	131 (29)	96 (21)	176 (39)	449 (100)

^*Includes nurse educators and specialists.

Interviews were conducted using a semistructured interview guide that included questions about management practices surrounding infection prevention, policies related to and enactment of UCNDPs, and perceptions of best practices for infection prevention in that hospital (see Appendix 1). We conducted most interviews in person, with some executive leaders interviewed by phone when necessary. Interviews were held during normal work hours in hospital conference rooms and unit break rooms and were either one-on-one or group interviews, depending on participants’ availability. Interview length ranged from 15 to 60 minutes with an average of 28 minutes. All interviews were audio recorded, transcribed verbatim, and de-identified.

Data Analysis

Consistent with rigorous qualitative research methods, we first developed a preliminary coding dictionary based on questions in the semistructured interview guide. Then, using this preliminary dictionary, three members of the coding team (AAG, MEG, SRM) coded the same five transcripts, noting new codes that emerged from the data. These new codes were incorporated into a revised coding dictionary, and the coding team then coded all of the interviews from the first five site visits. The coding team was overseen by the lead investigator (ASM) and met regularly throughout this preliminary coding process to ensure consistency in coding. As new themes emerged from the data, new iterations of the coding dictionary were developed, and coders re-coded transcripts to incorporate the new codes. Then, after coding and re-coding of transcripts from the first five sites was completed, the remaining 12 sites were coded by a single coder (AAG), thus ensuring a consistent and accurate coding process. We used the ATLAS.ti software (version 8.3.1) to support the coding and analysis process.

Our overall approach to coding was a deductive dominant thematic analysis,^29,30 but our identification of emergent codes and themes enabled a thorough exploration of our data. This approach allowed for comparison of themes across sites to characterize management practices important in infection prevention. Our approach allowed us to identify key management practices in CAUTI prevention and led to our focus on the implementation of UCNDPs as we describe in this paper. For these secondary analyses, using the complete coded dataset, we specifically focused on extracting data that described UCNDP implementation in a round of secondary coding led by a single coder (MJD). This analytic approach enabled us to identify and characterize the policies and practices that hospitals used to successfully implement UCNDPs as well as the challenges hospitals faced during the implementation process. Throughout this secondary coding process, our research team met regularly to discuss emergent themes and to develop consensus on the final interpretation of the results.

RESULTS

We found variation in the features of UCNDPs used by study hospitals, as well as commonality around both barriers to and facilitators of UCNDP implementation and use.

Variation in the Features of UCNDPs

Descriptions of UCNDP features and characteristics varied across hospitals—in particular, there was variation in how interviewees described the indications and procedures used by nurses to enact UCNDPs. Some UCNDPs specified how long an IUC could stay in place (e.g., 24–48 hours) before a nurse could remove it, provided no clinical indications remained at that time. Furthermore, physicians could write an order at the time of IUC insertion that could prevent the use of the UCNDP; in those cases, the nurses would need to confer with the physicians to remove the IUC. In other hospitals, however, UCNDPs were more physician-driven, requiring a physician to write an order at the time of catheter insertion for the UCNDP to be used before a nurse could actually remove a patient’s IUC. Regardless of the type of UCNDP, physicians had the authority to write “non-removal” orders if they decided an IUC needed to stay in place longer (e.g., to measure and monitor a patient’s urine output), and this would prevent the removal of the catheter by the nurse.

Interviewees commonly commented that UCNDPs gave nurses more autonomy and independence to decide if a patient met the criteria for removal, and some nurses appreciated having the ability to take action and remove a patient’s IUC without a physician order. In contrast, in hospitals that relied on physician orders to enact the UCNDP, nurses noted the need to clarify with the patient’s physician if the IUC should remain in place or be removed.

Barriers to Implementing UCNDPs

We identified three barriers to UCNDP implementation and use in acute care hospitals: (1) nurse deference to physicians, (2) physician push-back, and (3) miscommunication about IUC removal. Next, we describe these barriers in greater detail, including verbatim quotations that support our characterization of these barriers.

Nurse Deference to Physicians.

Although most hospitals had adopted UCNDPs by the time of the study, several interviewees suggested that some nurses were not implementing or consistently using UCNDPs. In these cases, nurses reported asking physicians if they wanted the IUC removed, even when the nurses had per-policy authority to remove the IUC without an order. One interviewee reflected, “I have to be honest I still think a lot of our nurses—we still check with our provider…I do think they need a little encouragement sometimes. I don’t think we are perfect yet. I don’t know if we are going to get perfect… Even though I know technically we can still do [the UCNDP]” (Assistant Nurse Manager). We found that, depending on the hospital, nurses would wait for a physician to tell them to remove an IUC or check with physicians to see what they wanted done rather than use the UCNDP. As an interviewee explained, “I don’t think [the UCNDP] is utilized that much, honestly. I think more or less, most of us wait for the doctor. If I think it should come out, I will at least ask them” (Nurse).

Physician Push-Back.

Another barrier we characterized was around physicians resisting use of the UCNDP. For instance, interviewees described physicians pushing back and wanting to keep IUCs in place despite patients meeting clinical indications for removal: “Are there still physicians who might push back and only want that Foley removed if they say so? Yes, I imagine that still exists to some extent. I think that was harder than it could’ve been or maybe should’ve been, but I think that still exists to some extent” (Director of Quality and Safety). When physicians pushed back, this affected UCNDP use because other nurses reported feeling less empowered to enact the protocol on their own. For example, as one nurse manager explained, “…most nurses do not feel comfortable just pulling a Foley. They really want to get the provider’s permission, despite us having that [UCNDP]. That is a big weakness and a lot of providers have push-back. They want to keep the Foley or maybe they are a covering provider and they are not really quite sure why it is in, and don’t you touch it, and let me figure this out, and that sort of thing” (Nurse Manager).

Miscommunication About IUC Removal.

Interviewees also indicated that there were times when care team members did not communicate clearly about when to remove IUCs in the context of using the UCNDP. For example, in situations where a physician order to keep an IUC in place was set to expire, nurses were not always confident they could use the UCNDP. As one nurse reflected, “…sometimes the order falls off, and no one addresses it. So, an improvement could be an easier sign of saying, ‘This order is going to fall off. Make sure you address it and get a new order,’ or you are actually going to take it out” (Nurse). Furthermore, when communication among care team members about the UCNDP was unclear, it led to future hesitation on the part of nurses to enact the protocol. For example, as one nurse explained, “[Our assistant manager] had a patient that she had use her [UCNDP] on and removed [the catheter] and the team was upset about it. They said it should have been in, but she had the order for the [UCNDP], so I think a little bit of miscommunication there. But, yeah, I think after that too I was definitely hesitant. If I think it should come out I will at least ask [the team]” (Nurse).

Facilitators of UCNDP Implementation

Our analysis also revealed several facilitators that contributed to the successful implementation and use of UCNDPs, including (1) training care team members to use the UCNDP, (2) discussing IUC necessity and UCNDP use during rounds, (3) reminding care team members to follow UCNDPs, and (4) developing buy-in for UCNDP use across the hospital. Interviewees often described these facilitators in the context of overcoming some of the identified barriers to UCNDP implementation presented above. Next, we describe these facilitators in greater detail, and we present Table 3 as a list of strategies that, based on our findings, could facilitate UCNDP implementation and use.

Table 3.

Strategies Identified to Facilitate UCNDP Implementation and Use

Strategy	Examples	Potential Impact(s)
Training care team members to use the UCNDP	Staff orientations that discuss systemwide policies for UCNDP implementation and use Ongoing educational seminars to review where, when, and how to enact UCNDPs	Develop the knowledge and skills of new care team members around IUC removal; provide consistent expectations about how UCNDPs should be implemented across hospital units
Discussing IUC necessity and UCNDP use during rounds	Conducting rounds to review patient treatment goals and plans around IUC use and removal Coach team members to enact UCNDP during daily rounds	Care team members feel empowered to enact UCNDPs more consistently; IUCs are removed more efficiently; care team members develop an understanding as to why an IUC may stay in place despite a patient meeting clinical indication
Reminding care team members to follow UCNDPs	Managers provide daily reports containing the names and status of patients who have IUCs Whiteboards are visible and updated every shift to identify care team members responsible for IUC oversight EMR notifications or alerts to prompt nurses to check patients who meet clinical indications for IUC removal	Care team members and managers are held accountable for patients who are eligible for catheter removal via an established UCNDP; care team members stay informed about changes to the status of catheterized patients
Developing buy-in for UCNDP use across the hospital	Designating an advisory committee to review and update policies that support UCNDP implementation Have interprofessional work groups share ideas or strategies to motivate frontline staff to enact the UCNDP	Increase awareness about the value of UCNDPs for reducing CAUTIs; address UCNDP implementation questions and identify opportunities to increase nurse enactment of an existing or newly implemented UCNDP

UCNDP, urinary catheter nurse-driven protocol; EMR, electronic medical record; IUC, indwelling urinary catheter.

Training Care Team Members to Use the UCNDP.

Training was reported as an important facilitator of UCNDP implementation because it gave care team members an opportunity to learn about the clinical indications for IUC removal. Training reinforced the use of the UCNDP and taught care team members, particularly nurses, what to be aware of when enacting the protocol. From nurse orientations to the informational resources provided at the unit level, interviewees described how training and education established expectations for nurses to take responsibility for carrying out the UCNDP at the hospital and why UCNDPs were important for preventing CAUTIs. Training was seen as a way to educate frontline staff about what clinical indications they needed to look out for in order to use the UCNDP appropriately and minimize the risk of leaving an IUC in for too long or having to reinsert it at a later time. These trainings were also fundamental to encourage nurses to actively identify patients who no longer required an IUC. Several interviewees similarly described how UCNDPs were emphasized in trainings offered to frontline staff (e.g., unit-specific training programs), making it clear that enacting this UCNDP was a priority across hospital units. For example, one interviewee described that having ongoing education involving unit-based nurse educators and frontline staff enabled a “peer-to-peer kind of knowledge transfer” (Unit Nurse Manager) that made nurses more comfortable using a new UCNDP.

Discussing IUC Necessity and UCNDP Use During Rounds.

Rounding was another common facilitator of UCNDP implementation because it made nurses more aware about using UCNDPs and their management of the patients who had an IUC in place. Discussions about the necessity of these catheters during rounds also reportedly helped nurses become more comfortable with using the UCNDP, and thus made it less likely an IUC would be used inappropriately. As one interviewee reflected, “We do understand the protocol and we do talk to [care team members] about things like, we want to know when we’re out rounding on Foleys, ‘Is this needed? Are we talking about taking this Foley out, or do you know about bladder scan? Are you going to bladder scan after you pull it?’ We talk to them about those kinds of things. So most of the time I feel really confident about where they are with—and most of the time when there is a Foley in place” (Quality Nurse Specialist). We found that all types of rounds (e.g., nurse rounds, interprofessional rounds) seemed to play a role in facilitating UCNDP use. For instance, nursing rounds allowed opportunities to review the placement of patients’ IUCs and describe challenges around enacting the UCNDP in the psychologically safe environment of other nurses.

Interprofessional rounds allowed real-time discussion and decision making around the UCNDP and opportunity to remove IUCs when this was clinically indicated. Physician rounds could also address patients’ needs for IUCs, particularly when there was a process in place wherein which physicians were prompted to explicitly consider the opportunity for catheter removal during those rounds (e.g., a checklist on patients’ doors prompting physicians to think through the criteria for removal during their rounds).

Reminding Care Team Members to Follow UCNDPs.

As the goal for a UCNDP is to empower nurses to remove IUCs when it is appropriate to do so, having processes or systems in place to make sure frontline staff follow UCNDPs was noted as an important facilitator of UCNDP implementation. In one hospital, managers shared messages from clinical practice councils with nurses during daily huddles reminding them to use UCNDPs. In other hospitals, unit managers also maintained a daily list of patients who had IUCs, which served as a reminder to nurses to use the UCNDP or to check in with certain patients to see if they met the criteria for enacting the UCNDP.

Some hospitals developed and incorporated electronic medical record (EMR) alerts so that nurses and other care team members would know when it was time for a nurse to use the UCNDP to take out a patient’s IUC. As one interviewee explained, “Even the [UCNDP], that’s all built into our EMR and then into our order so that they know, you know, it’s day 2, this catheter needs to come out” (Nurse). In some hospitals, these alerts would happen throughout the day or at multiple times during a nurse’s shift to make sure the nurse was keeping track of the patients’ clinical indications for removal. Having these notifications built into the EMR was viewed as a helpful reminder for nurses to follow the UCNDP.

Developing Buy-in for UCNDP Use Across the Hospital.

Interviewees also discussed the importance of having mechanisms in place to develop buy-in from different departments and levels of management to use UCNDPs. Shared governance meetings were one way clinicians and managers could share ideas to promote the use of UCNDPs and encourage nurses to use them consistently. For instance, one hospital introduced the idea of a “float pass”—that is, if a nurse used the UCNDP, they were eligible to not have to work on another unit to cover staffing needs (Nurse Manager). Interviewees described that getting the UCNDP endorsed across the hospital necessitated collaborative discussions between clinicians and hospital leadership responsible for developing and implementing quality and patient safety policies. In these cases, collaboratives and working groups spanning clinical and administrative domains helped to systematize infection prevention policies including UCNDPs because stakeholders participating in those meetings were able to develop agreement about the appropriateness of the policy and its use across the hospital.

DISCUSSION

Although CAUTIs remain a prominent patient safety concern, UCNDPs offer hospitals an effective strategy to mitigate their risk when successfully implemented.²⁰ Our study suggests that hospitals have opportunities to make changes to accommodate UCNDP implementation and promote its use. In studying how health care providers, managers, and executives described their experiences with UCNDPs in the context of CAUTI prevention, we found that some hospitals were having difficulty overcoming physician push-back and nurse reluctance to enact existing UCNDPs. We also identified facilitators that contributed to the successful implementation of UCNDPs in these hospital settings; specifically, training, rounding, reminding, and developing buy-in around existing UCNDPs. These facilitators share similarities with components of other successful UCNDP programs^11,15,31 shown to lower rates of IUC use and reduce infections. For example, the implementation of daily CAUTI rounds to evaluate patients’ continued need for an IUC was an important aspect of a multimodal CAUTI prevention bundle that helped reduce both catheter utilization and CAUTI rates in a surgical trauma ICU.³¹

The facilitators we characterized in this study describe different ways hospitals can encourage nurses to use UCNDPs and ultimately prevent patient harm and are consistent with previous research that has identified factors important in supporting UCNDP implementation and use.²⁶ For instance, one study noted that obtaining consensus from physicians about the criteria for removing IUCs and engaging nurse leaders in the decision-making process can facilitate the implementation of UCNDPs.¹⁶ Other quality improvement initiatives have also identified the importance of aligning resources and leadership support to ensure UCNDPs are implemented as designed.¹⁴

Our findings suggest that the implementation of UCNDPs requires both hospital leaders and physicians to empower nurses to enact the UCNDP. In situations where a physician pushes back and orders an IUC to be reinserted, nurses may feel less confident about enacting a UCNDP, making it more important to have processes in place for the physician and nurse to discuss the rationale behind reinsertion (e.g., interprofessional rounds). We also found that miscommunication about IUC removal could potentially make nurses more reluctant to enact the UCNDP because it may not be clear to them when removal is appropriate for certain patients. Our findings about notifying and reminding nurses about patients who have IUCs through the use of patient lists or EMR alerts are important in the context of UCNDP implementation. Ensuring an up-to-date record of which patients have IUCs and which patients meet the criteria for removal can ensure that all care team members can hold each other accountable for catheter removal consistent with the UCNDP. Additionally, as noted in prior studies, ongoing verbal or written reminders can serve as cues for care team members to change their behavior, because they can encourage care team members to assess the continued need for IUCs and to adhere to specific evidence-based practices or programs.^32,33 Hospital units may find it useful to involve nurses in developing reminder systems, such as daily reports or checklists, to ensure the data are timely and reflect the current state of IUC use in their areas.

Our research also sheds light on the need for a more nurse-focused approach to UCNDP implementation. For example, nurses may have different knowledge about the importance of timely IUC removal, variable skill levels that impact their ability to enact the UCNDP, or differing levels of comfort in asserting to the physician their recommendation to remove the IUC^34,35 (e.g., when a patient meets clinical criteria for removal, but the patient or physician wants the IUC to stay in place). Without addressing these nurse-level concerns, it is possible that UCNDP implementation will remain incomplete. Therefore, effective UCNDP implementation will likely involve prompted, daily assessments of indication-based need and include nurse authority to remove an IUC without contacting the physician; in this context, nurses will be supported by broad education, physician counseling, and leadership endorsement of UCNDP enactment. Nurse training and developing buy-in for UCNDP enactment can also potentially empower nurses to routinely use UCNDPs and, ultimately, support CAUTI prevention. Finally, by emphasizing alternatives such as noninvasive collection systems, deploying supplies for safe patient handling, and mobilizing additional staff,^27,36 hospitals may further reduce nurses’ reluctance to remove IUCs and thus increase the likelihood of UCNDP implementation success.

Limitations

Our study has several limitations. First, although the purpose of our research was to examine factors promoting and limiting UCNDP implementation and use, we did not explicitly measure implementation effectiveness or success. Future research may help improve our understanding of which factors are associated with implementation effectiveness. Second, we were not able to differentiate physician participants based on their specialty (e.g., urology vs. cardiology) and we recognize that this distinction may influence support of UCNDPs. It will be important for future research to identify whether differences in physicians’ opinions or preferences about using UCNDPs can help explain variations in UCNDP implementation and CAUTI prevention. Third, as the interviews we analyzed for this study were conducted as part of a broader research project that examined management practices supporting HAI prevention, there may be additional barriers to and facilitators of UCNDP implementation that would be mentioned in a study explicitly focused on this topic. Fourth, we acknowledge that hospitals may have been at different stages with respect to their implementation of a UCNDP (e.g., early vs. late stages of implementation). Further study, guided by an implementation science framework, for instance, is necessary to understand whether the implementation time frame might influence UCNDP use and whether barriers and facilitators might differ based on this time frame. Finally, our purposive approach to site recruitment resulted in around half of the hospitals we approached (51%) declining to participate in site visits. While it is possible our findings may be biased by nonparticipation, the number and variety of hospitals that did participate give us confidence that the findings we report are robust.

CONCLUSION

We found that strategies such as training, rounding, reminding, and developing buy-in facilitated UCNDP implementation and were perceived to help hospitals overcome barriers to using UCNDPs. Our findings thus have important implications for managers who are responsible for implementing changes to improve patient safety, and especially those focused on infection prevention. Specifically, empowering and supporting nurses to enact UCNDPs may be fundamental to facilitating the implementation of evidence-based practices that can improve the quality of care delivered and address patient safety issues such as CAUTI prevention.

Appendix 1. Interview Topics from the Semi-Structured Interview Guide Used During Site Visits

Introduction: Interviewee Background

• To start, for our records, please tell us your name, your current role or title, and how long you have been in that position?

Section 1: Goal Setting and Support

High--performing hospitals that are successful in reducing and preventing healthcare--associated infections (HAIs) such as central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) have established aggressive goals. In prior work we have identified a variety of structural practices that are important for successful goal setting and support. If these are in place at your hospital, we would like to learn how these strategies have been implemented and are used.

• Does your hospital have specific goals for HAIs?

  • What is the goal for the number of CLABSIs in your hospital?
  • What is the goal for the number of CAUTIs in your hospital?
  • How are the actions you and your colleagues should take to support these goals communicated to you?
• How does your hospital communicate about HAI prevention goals?

  • Written communications—can be electronic (e.g., emails, posters, fliers, employee intranet, bulletin boards)
  • Oral communications (e.g., huddles, unit meetings, rounds, leadership meetings, presentations to the Board, quality meetings, town hall meetings, lectures)
• When you learn about these goals, does that make you do things differently?

  • Do your managers tell you how to adjust your priorities to meet these goals?

• Who is responsible for infection prevention in your hospital?

• How does your hospital define accountability (for goals)?

  • How is accountability ensured?
• How is hospital leadership involved in and aware of HAI prevention?

  • How does your hospital demonstrate that leaders have bought in to HAI prevention goals? (e.g., visible presence, leadership rounds, etc.)
• What does your hospital do to ensure that sufficient resources are in place to help prevent HAIs?

  • Personnel Resources (i.e., staff, staffing priorities)
  • Supply Resources (i.e., supplies, equipment, technologies)

Section 2: Strategic Alignment/Communication and Information Sharing

High -performing hospitals that are successful in reducing HAIs such as CLABSIs and CAUTIs use strategic communications and widely share information about infection prevention. Again, several structural practices have been identified as important to strategic alignment and information sharing, and if these are in place at your hospital, we would like to learn how these strategies have been implemented and are used.

• What things (practices, processes) are in place in your hospital that promote infection prevention?

  (e.g., clinical processes--nurse-driven protocols, standard of care policy documents, standardized order sets)

  (e.g., operational processes--audits of the processes, handoff reports, checklists)

  • If checklists, What type of information is listed on your nurse checklist?
    (e.g., management processes--identify and use champions, rounding of infection preventionists, leadership rounding, team development)
  • If management processes, Are these processes the same across units?

• What is done to investigate when infections are found? (e.g., on the floor investigations, talk to staff, track trends)

• How is information about infections and infection prevention shared at your hospital?

  • Unit-level communications (e.g., huddles, unit meetings, rounds etc.)
  • System-level communications (e.g., employee Intranet, public display of data, signage, newsletters)

• If an infection is found that seems not to be associated with a stay in your hospital, what happens with that infection?

• Does your hospital use storytelling to emphasize the importance of infection prevention? (e.g., about patients with infections, about financial impact)

Section 3: Use of Information Technologies

The use of information technologies has also been identified as important in efforts to reduce and prevent HAIs, so we would like to learn how health information technologies are used here.

• What things (practices, processes) are in place in your hospital’s EMR/EHR that promote infection prevention? (e.g., EMR decision support tools, EMR alerts, standardized order sets, information system flags for Foleys, checklists)

• Are there any best practice alerts in your EMR related to infection prevention?

• Are there any other ways your EHR or information technologies are used to help prevent infections?

Section 4: Systematic Education

High--performing hospitals that are successful in reducing HAIs such as CLABSIs and CAUTIs educate their employees on a regular basis about infection prevention. With respect to systematic education, if these structural practices are in place at your hospital, we would like to learn how these strategies have been implemented and are used.

• What types of education are provided to you regarding infection prevention? (e.g., about standards for HAI prevention, standards of care, policies and guidelines)

• Does education content and approach vary by type of provider? (e.g., for staff, students)

• What approaches to education are used at your hospital? (e.g., CBLs, videos, handouts, in-service, online, train champions, in-person testing annually, journal club/assignments, CEUs, CNE)

  • How frequently do education sessions take place?
  • Does your organization provide reminders or educational refresher or “booster” sessions?

• How does your hospital educate patients (visitors, guests) about infection prevention?

Section 5: Inter-professional Collaboration

High--performing hospitals that are successful in reducing HAIs such as CLABSIs and CAUTIs collaborate across professions.

• How does your hospital promote or support Inter-professional work? (e.g., across physicians, nurses, physical therapists, occupational therapists, case managers--create interdisciplinary committees, team building)

• How does your hospital facilitate good physician-nurse relationships?

  • Does your hospital intentionally encourage staff to speak up when they observe breaches of infection prevention protocol or patient safety?
  • Does your unit specifically encourage staff to speak up? (Can you describe how that occurs?)
  • Have you ever spoken up when someone did not follow protocol? Can you describe what happened? (Was it a peer? A physician?)

• What does your hospital do to support a culture of collaboration? (e.g., support collaboration, promote a change-oriented culture, build trust)

• Are there other ways in which a hospital could support inter-professional collaboration to reduce HAIs? (Probes: For CLABSIs? For CAUTIs? For other infections?)

Section 6: Meaningful Use of Data

High--performing hospitals that are successful in reducing HAIs such as CLABSIs and CAUTIs use data meaningfully and widely share information about infection prevention.

• What types of HAI information does your organization share with you? (e.g., specific metrics, current rates, numbers of infections, scorecards, infection rates, process measures, rates of peers, financial burden)

  • How is this information shared with you and your care team? (e.g., email, in-person meetings)
  • Does your unit post infection data where you can see it? Where?
  • When the numbers change, how do you know? (who updates it?)

• Do you have concerns about the quality or timeliness of this data?

• With what groups and individuals does your hospital share HAI rates? (Probes: For CLABSIs? For CAUTIs? For other infections?)

  • Internal audiences (e.g., providers, frontline staff)
  • External audiences (e.g., patients, public ally visible, everyone)
• Does your hospital share information about best practices in infection prevention?

  • At the unit level? (i.e., compare processes between units for successes/challenges in infection prevention)
  • At the hospital level? (i.e., compare processes between hospitals for successes/challenges in infection prevention)

Section 7: Recognition for Success

High--performing hospitals that are successful in reducing HAIs such as CLABSIs and CAUTIs recognize success at achieving HAI- reduction goals.

• How is success recognized with respect to infection prevention? (Probes: Unit level? Individual employee? Hospital-wide?)

  • Rewards (bonus system, reward program)
  • Penalties (financial penalties, audits)

• Are there other ways in which a hospital could recognize successes related to reducing and preventing HAIs?

Interview Closure and Follow-Up

• Is there a difference in your approach to infection prevention for CLABSIs and CAUTIs?

• Does your hospital have particular best practices in infection prevention that you would like to share?

• Is there anything else you would like to tell us about your hospital’s strategies to promote CLABSI- or CAUTI-prevention?