NPSF Patient Safety Insight Logo

Lessons Learned: Implementing Practices to Improve CLABSI Rates

On Jun 12, 2013

Children’s Hospital of Philadelphia Home Care invested time and focused, sustained efforts in implementing the World Health Organization’s Five Moments for Hand Hygiene as part of a safety initiative in reducing its CLABSI rate. Implementation resulted in a reduction in infection rates; lessons learned; best practices and changes in mental models, such as a redefinition of “team”; and system-level changes such as innovative, coordinated, community-level educational outreach.

by Verna Cole, PhD, & Kelly Monacella-Duffy, MSN, RN


Patient care is delivered by systems as well as by the individuals utilizing them; patient safety improvement must include individual, group, and organizational learning (Edmondson and Moingeon 1998). Few organizations share their experiences with other health care entities on recursive steps and successful strategies identified as part of their organizational learning while implementing patient safety initiatives. This article highlights the individual, collective, and organizational learning achieved as Children’s Hospital of Philadelphia (CHOP) Home Care implemented new initiatives for infection control targeted at decreasing central line-associated bloodstream infections (CLABSI).

Through surveys and semi-structured interviews with field nurses, their immediate supervisors, and department leaders, a qualitative study of home care nurses’ experiences during this implementation was conducted. Four initial surveys and 10 interviews were completed. The interviews detail staff understanding of how front-line experiences were moved from lessons learned to best practices to system-based practice.

The implementation of a practice change is a process that takes effort and time. Organizational learning is particularly relevant during all stages of implementation because processes such as information transfer, skilled management of the change process in specific settings, and in-depth understanding of the dynamics at play are needed to ensure adequate time, focus, and attention to resource management in supporting continuous improvement while limiting risk, and monitoring for unintended consequences.


Patient safety is the application of safety science methods toward a health care delivery system to minimize safety incidences and adverse events (Emanuel et al. 2008). A culture of safety comprises numerous factors and may include the healthcare agency’s ability to: 1) integrate individual and group learning from patient safety initiatives with current policies, processes, and practices; and 2) improve, spread, and sustain the changes (Jones et al. 2008). Essentially, the way organizational learning is managed affects the adoption of initiatives, the rate of improvements, and organizational performance (Edmonson et al. 2006).

Organizational learning can be defined as “developing the capacity to transfer knowledge across the organization, to share expertise and information while purposefully, continually adapting and growing together (Rowley and Poon 2010). It encompasses five core disciplines: systems thinking, team learning, shared vision, mental models, and personal mastery (Senge 1990).

CHOP Home Care’s Infection Prevention & Control Program provides surveillance and guidelines for the prevention and control of the spread of infectious pathogens to patients, caregivers, and health professionals in the home care setting. Since 2009, the goal for CHOP Home Care’s CLABSI rate has been fewer than 2 infections/1,000 line days. CHOP Home Care’s performance has shown progress and sustained improvement for several years. Progress is attributed to standardized practices, as outlined in CHOP’s policy and procedures, consistency in practice by all clinicians, and patient/family education on central-line management. ...

The rest of this article is available for ASPPS members only.
Login or Join
Powered by wordpress membership plugin MemberWing-X

Categories : Magazine, Spring 2013

Leave a Reply

+ 5 = 10