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Address correspondence to Mohamad G. Fakih, MD, MPH, Medical Director, Infection Prevention and Control, St John Hospital and Medical Center, 19251 Mack Ave, Ste 190, Grosse Pointe Woods, MI 48236.
Preventing catheter-associated urinary tract infection (CAUTI) remains a significant challenge for US hospitals. The “On the CUSP: Stop CAUTI” initiative represents the single largest national effort (involving >950 hospitals) to mitigate urinary catheter risk. The program brings together key organizations to assist state hospital associations and hospitals by providing education and coaching support, addressing both the technical aspects of preventing CAUTI and CAUTI-specific socio-adaptive challenges. At the local level, engaging health care workers, from physicians and nurses to other ancillary services, is critical. This includes (1) making the importance of addressing CAUTI stakeholder specific, (2) ensuring support from leaders of essential disciplines, (3) underscoring the importance of the collaborative nature of CAUTI prevention, and (4) identifying champions within the organization to lead and be accountable for the work. Sustainability is ensured by integrating the process into the health care worker's daily routine activities.
Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America.
Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010.
Since October 2008, the Centers for Medicare and Medicaid Services have not reimbursed for hospital-acquired catheter-associated urinary tract infection (CAUTI), considering it to be a reasonably preventable condition.
In addition, the US Department of Health and Human Services' National Action Plan to prevent healthcare-associated infections includes a 25% reduction in CAUTI rates nationwide by 2013.
Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
Among the efforts to meet this goal is the national implementation of Comprehensive Unit-based Safety Program (CUSP) to reduce CAUTI initiative, also known as the initiative—On the CUSP: Stop CAUTI—which is funded by the Agency for Healthcare Research and Quality (AHRQ) and led by several institutions and societies. Specifically, this AHRQ-funded effort, led by the Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association, in collaboration with the Michigan Health & Hospital Association (MHA) Keystone Center for Patient Safety & Quality, St John Hospital and Medical Center, Veterans Affairs/University of Michigan Patient Safety Enhancement Program, and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, is designed to reduce CAUTI, improve unit safety culture, and reduce CAUTI risk.
Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
In this article, we discuss CAUTI prevention efforts, describe the national collaboration between the different organizations, briefly review the technical and socio-adaptive components of the program, and specifically describe our approach to engaging health care workers (HCWs) as an essential part of CAUTI prevention and averting patient harm. Strategies to ensure sustained improvements are also discussed.
CAUTI prevention
Much of the effort to prevent CAUTI has been geared toward reducing device use.
In 2009, the Centers for Disease Control (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC) issued new guidelines for CAUTI prevention, including consensus-based indications for appropriate use.
Although based on expert opinion, the recommended indications are largely viewed as acceptable indications for catheter use, and hospitals have been encouraged to adopt them. The 6 appropriate indications are as follows: (1) acute urinary retention or bladder outlet obstruction, (2) accurate measurements of urinary output in critically ill patients, (3) perioperative use for selected surgical procedures, (4) to assist in healing of open sacral or perineal wounds in incontinent patients, (5) prolonged immobilization requirement, and (6) improved comfort for end-of-life care. In addition, the HICPAC CAUTI guidelines promote proper aseptic insertion and maintenance techniques.
Nonetheless, unnecessary placement and continued use of urinary catheters remains common in hospitalized patients, especially among vulnerable populations, such as older adults.
The risk exists as soon as the patient reaches the hospital, in the emergency department (ED), on both the intensive care unit (ICU) and the medical surgical floor, or in the operating room (OR). Mitigating the risks associated with catheter use includes addressing both appropriate reasons for use and proper insertion technique and catheter maintenance. The urinary catheter life cycle, described by Meddings and Saint,
provides a useful framework for both identifying and addressing this risk (Fig 1). For example, to reduce catheter harm, the first step is to prevent placement of any urinary catheter that would not be of medical benefit to the patient.
Step 2, aseptic insertion and proper maintenance, reduces the risk of introducing organisms into the bladder, delaying the occurrence of bacteriuria. Removal of the catheter when it is no longer medically needed (step 3) reduces the risk of noninfectious and infectious complications. Catheter-associated bacteriuria is dependent on duration of use,
Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
Step 4 of the lifecycle focuses on preventing reinsertion of indwelling urethral catheters, which may involve the use of alternative strategies, such as bladder scanning and intermittent catheterization, as described in the algorithm provided in Figure 2.
Fig 1Lifecycle of the urinary catheter, which includes placement, care, removal, and reinsertion.
(Reproduced with Permission. Meddings and Saint, Clin Infect Dis 2011;52:1291–93.)
the MHA Keystone Center implemented a process to reduce inappropriate catheter use in 163 units from 71 acute care hospitals in the state of Michigan. This program resulted in a 25% relative reduction in catheter use and a 30% improvement in appropriate use,
The Michigan work used a bladder bundle that promotes daily evaluation of catheter need, use of tools (eg, bladder ultrasound) to prevent catheterization, and evaluation and feedback on catheter use and appropriateness.
Building on the Michigan approach and with funding support from the AHRQ, 10 organizations, considered to be important stakeholders in reducing catheter harm, collaborated to plan and implement the On the CUSP: Stop CAUTI project in all 50 states. The HRET leads the project, providing oversight, coordinating the work between the different organizations, and serving as a conduit to state hospital associations and other entities working with hospitals. Since the project's inception in August 2011, a national project team with representatives from the MHA, University of Michigan, St John Hospital and Medical Center, and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality has been working with the HRET to guide the CAUTI prevention work that is now underway. The roles of the national team members are described in Table 1. In addition to the national team, extended faculty was recruited from the Association for Professionals in Infection Control, Society of Healthcare Epidemiology of America, Society of Hospital Medicine, Emergency Nursing Association, and American College of Emergency Physicians (Table 1). The role of the extended faculty ranges from spreading the educational efforts nationwide, providing insight in their area of expertise, and garnering support for the initiative with their respective members. Finally, representatives from the CDC provide technical assistance and guidance to the national team.
Table 1Roles of the different entities in the national effort
Entity
Expertise
Role
HRET
Administration and coordination of initiatives
Provide oversight of the national implementation effort; serve as a liaison with the 50 state hospital associations to recruit hospitals, implement education and improvements, and build capacity for sustainability; help coordinate the efforts between the different entities partnering in the project
MHA Keystone Center for Patient Safety
Implementation of patient safety initiatives, implemented the initial statewide efforts in Michigan that led to significant reduction in urinary catheter use
Contribute to the development and coordination of project's education and coaching; responsible for data collection and reporting
University of Michigan
Faculty members are leaders in CAUTI research from evaluation to intervention, with technical and socio-adaptive expertise, data evaluation, and readiness assessment
National faculty responsible for education related to socio-adaptive aspect of reducing CAUTI, data evaluation, expert guidance on the project progress, and suggesting improvements
St John Hospital and Medical Center
Faculty members are experts in implementation of CAUTI reduction efforts; implemented the initial nurse-driven effort to reduce unnecessary catheter use in addition to efforts to reduce catheter placement in the ED
National faculty responsible for education of the technical component, data evaluation, expert guidance on the project progress, and suggesting improvements
Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality
Experts in CUSP
Faculty for initial CUSP educational sessions; supports the HRET and MHA on content specific to CUSP and its use to prevent CAUTI
CDC
Expertise in CAUTI prevention and the definition of CAUTI
Provide technical advice for states to improve their infrastructure to improve readiness for healthcare-associated infection prevention; advice related to CAUTI definition
Association of Professionals in Infection Control
Expertise in CAUTI prevention, and the CDC CAUTI definition
Extended faculties build capacity for educating facilities, with focus of reducing infection risk and the proper use of the CAUTI definition to measure outcomes
Emergency Nurses Association
Expertise in the emergency setting
Extended faculties serve as the liaison with the emergency nurses through their society, build capacity for educating emergency nurses with focus on avoiding catheter use unless there is an appropriate indication, and support the interventions in recruited EDs
Society of Hospital Medicine
Expertise in education through a mentoring program
Extended faculties serve as a liaison with hospitalists who may play a key role in reducing unnecessary urinary catheter use
Society of Healthcare Epidemiology of America
Expertise in CAUTI prevention and the CDC CAUTI definition
Extended faculties build capacity for educating facilities, with focus of reducing infection risk and the proper use of the CAUTI definition to measure outcomes
American College of Emergency Physicians
Expertise in the emergency setting
Faculty serves as the liaison with the emergency physicians through their society, builds capacity for educating emergency physicians with focus on avoiding catheter use unless there is an appropriate indication, and supports the interventions in recruited EDs
The On the CUSP: Stop CAUTI effort is initiated for groups of states at a time (or cohorts), beginning with the engagement of the various state leads who serve as a liaison with the hospitals. Interested hospitals are expected to obtain leadership support and identify specific units for their improvement work. Hospitals are also provided with tools to help them assemble their CAUTI prevention teams and resources to support their efforts. The importance of addressing both the technical and socio-adaptive components of CAUTI prevention is stressed throughout program implementation.
Hospital teams are educated on the epidemiology of urinary catheter use and CAUTIs, CDC HICPAC consensus-based guidelines for urinary catheter use, and evidence-based practices applicable to catheter placement and maintenance.
The technical aspect also includes a focus on evaluating daily necessity for patients with an indwelling urinary catheter.
Education about the socio-adaptive elements of CAUTI prevention includes strategies to gain the support of all team members. Specifically, the CUSP model is used to help create a culture of safety in the involved hospitals.
In addition, the socio-adaptive component focuses on providing support to HCWs, addressing challenges to implementation, and offering solutions to overcome possible barriers.
This focus on socio-adaptive issues is critical because preventing CAUTI is primarily behaviorally focused, requiring engagement, collaboration, and communication across professional disciplines and clinical and administrative boundaries.
General approaches for addressing both the technical and socio-adaptive aspects of CAUTI prevention as part of the On the CUSP: Stop CAUTI effort have been previously described.
Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
However, specific strategies, especially those for engaging a diverse range of HCWs have not been well described, despite being a critical element of preventing CAUTI and reducing risk of patient harm.
Engaging HCWs and the ideal team
As an important element of socio-adaptive change, HCW engagement at the hospital level is an essential component for successful implementation of the CAUTI prevention work. This includes the range of HCWs and potential stakeholders who provide patient care and are expected to incorporate the implementation of the CAUTI prevention practices into their daily work. The engagement process includes the following: (1) making the case for the importance of addressing CAUTI for different stakeholders, (2) ensuring support of the leaders of essential groups, (3) underscoring the importance of the collaborative nature of the effort, and (4) identifying champions to lead and be accountable for the work.
Making the case for different stakeholders
Many stakeholders have an interest in helping to reduce CAUTI. Traditionally, infection prevention has championed the effort to reduce CAUTI, viewing CAUTI as a preventable healthcare-associated infection. More recently, hospital administrative leaders have also recognized and supported many of the initiatives to reduce CAUTI, given that CAUTI is no longer a reimbursable event,
Centers for Medicare and Medicaid Services (CMS), HHS Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and Fiscal Year 2014 rates; quality reporting requirements for specific providers; hospital conditions of participation; payment policies related to patient status. Final rules.
Administrative leadership support may provide a significant incentive for the different hospital disciplines to support the work to reduce CAUTI. However, in focusing on urinary catheter harm more broadly as the principal event to prevent, other disciplines may also be encouraged to help. For example, urinary catheter presence likely leads to more urine cultures and antimicrobial treatment of asymptomatic bacteriuria,
Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010.
In addition, urinary catheter use is associated with local trauma, patient discomfort, immobility, and potentially, the risk of pressure ulcers and falls.
Engaging the different disciplines and pointing out the reasons why the work is important to them will help gain the support needed to succeed. Table 2 summarizes the potential harm related to the catheter and reasons why different disciplines should be interested in supporting the work.
Table 2Disciplines and specialties and their incentives to support minimizing urinary catheter harm
Discipline or specialty
Urinary catheter harm
Hospital epidemiology, infection prevention, and infectious diseases
Infectious complications: CAUTI, multidrug resistance, C difficile infection, and improve antimicrobial stewardship
Urology
Mechanical complications: hematuria, meatal and urethral injury
Geriatric medicine
Infectious and noninfectious complications: significant proportion of inappropriate catheterization in older adults, leading to increased immobility and deconditioning risk, in addition to infection and trauma
Hospital medicine
Infectious and noninfectious complications: hospitalists care for a large number of patients; their support may significantly improve the appropriate use of urinary catheters resulting also in shorter length of stay
Rehabilitation medicine and physical therapy
Urinary catheter impedes mobility (1-point restraint), and may be associated with an increased risk of falls
Wound ostomy services
Urinary catheter use increases immobility, which in turn results in an increased risk of pressure ulcers; wound care nurses may help in advising the bedside nurse on methods to reduce skin breakdown in patients with incontinence without using urinary catheters
Surgery
Avoid postoperative complications: the surgeons need to comply with the Surgical Care Improvement Project recommendations to remove catheters by postoperative day 1 or 2; inappropriate urinary catheter use postoperatively will negatively affect the surgeon's profile
Intensive care nurses and physicians
CAUTI is publicly reported in the ICUs; the ICU has the highest prevalence of urinary catheter use compared with other hospital units; opportunities to reduce urinary catheter use exist through daily evaluation of need and on transfer from the ICU to floor
Emergency medicine nurses and physicians
ED represents the point of entry to more than half of the patients admitted to the hospital; unnecessary urinary catheter placement is common in the ED, and promoting appropriate placement will affect use hospital-wide
Administrative leaders
Inappropriate urinary catheter use subjects the patient to preventable safety risk; in addition, the Centers for Medicare and Medicaid Services have stopped compensation for hospital-acquired conditions; moreover, CAUTIs are publicly reported and are tied to value-based purchasing and hospital-acquired condition payment penalty
ED, emergency department; ICU, intensive care unit.
Specifically, it is helpful to address each discipline's clinical interests and make the case for why this effort is of value to them and their patients. Each group's perception is different; therefore, engaging them needs to take into account their unique priorities. The infection prevention team views reducing urinary catheter use as a critical factor for lowering CAUTI events, antimicrobial use, C difficile infections, and minimizing an important reservoir for multidrug resistant organisms. Urologists are interested in avoiding any mechanical complications related to the catheter (eg, urethral trauma, hematuria). Hospitalists and geriatricians may view the invasive nature of the catheter with its infectious and debilitating effects on already frail patients as important reasons for minimizing catheter use. Physical therapists consider the urinary catheter another barrier that hinders the patient's mobility, therefore delaying the rehabilitation process. Similarly, intensive care nurses and physicians working on early mobility in intubated patients have an incentive to remove the catheter as soon as the patient's critical illness no longer requires hourly output monitoring. In addition, public reporting of CAUTI and linking it to value-based purchasing have increased the pressure placed on intensive care unit teams by administrative leaders. Wound care nurses are concerned about the risk of pressure ulcers and wound deterioration in an incontinent patient, but they also recognize the importance of reducing device-related pressure ulcer risks and risks associated with immobility. Finally, the ED clinicians play a very special role in minimizing avoidable device exposure, supporting all other hospital units and disciplines.
Ensuring the support of leaders
After identifying the stakeholders, engaging their leaders is of paramount importance. The leader's involvement may range from being a staunch supporter of the initiative to a barrier to optimal implementation.
Successful leaders promote a culture of clinical excellence and effectively communicate it to staff, inspire staff to follow their lead, help overcome barriers to adoption of new processes, and “think strategically while acting locally” to move initiatives forward.
In contrast, active resisters plainly voice their opposition to the process, whereas organizational constipators may undermine the work without clearly showing their lack of support.
Engaging active resisters and organizational constipators and including them in discussions to implement changes in the hospital may help obtain their support.
Understanding the collaborative nature of the effort
Reducing CAUTI requires both nurse and physician support. Although a physician order has been historically viewed as essential to place or discontinue the catheter, nurses may be empowered to make decisions about removal without a physician order in some settings,
In a recent survey, the vast majority of nurses viewed themselves as responsible for the evaluation and discontinuation of the catheter, but only two-thirds thought it does not affect their workload.
Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
with many requiring physician approval for discontinuation. Even with physician-independent discontinuation protocols, physician support is a key to success. For example, a hospital recently implemented a process for physician-independent discontinuation of urinary catheters based on agreed institutional guidelines. This process included the involvement of nursing leadership, quality improvement, and key administrative physician leaders, but it was not discussed with urology. Early in its implementation, a urinary catheter was removed erroneously in a patient postprostatectomy; this led to strong resistance to the process from urology, and consequently, the program was halted (personal observation, MGF).
Collaboration between departments is also critical to success. The ED and OR are areas where large numbers of urinary catheters are placed, and the intensive care units represent areas of high prevalence of use.
Intervening to prevent inappropriate catheter placement in the ED and the OR will help reduce the use of catheters in the nonintensive care units. In addition, removal of no-longer needed catheters in patients on transfer out from the intensive care units will also help lower urinary catheter prevalence in the nonintensive care units.
Identifying champions to lead and be accountable for the effort
The recommended champion is a HCW, preferably from the same unit, who is motivated and engaged in improving safety. The champion may be either a physician, a nurse, or in some instances, a member of other supporting services. Successful champions are those who believe in the safety efforts, have the recognition and respect of their coworkers, and are early adopters of change.
The champion's role is to reduce CAUTI risk by promoting best practices. Ensuring that the champion is fully versed on the individual institution's best practices is essential. For example, he/she needs to know the appropriate indications for urinary catheter use and identify the potential barriers and facilitators. The champion acts as a liaison among all HCWs, engaging all of the stakeholders who are involved in patient care. One of the champion's functions is to maintain the focus on reducing urinary catheter risk as a patient safety priority. The champion may share patient stories with HCWs to improve their perception of the potential risk to patients. The champion needs to elucidate significant risks associated with urinary catheters and may share examples of poor patient outcomes related to not following best practices. The champion may promote best practices to others by distributing educational materials, providing presentations, and offering other tools that help HCWs adhere to best practices. The champion will also help identify barriers to implementation and develop solutions with other stakeholders. Finally, a very important role of the champion is providing performance feedback to all stakeholders. For example, the champion may identify a sizable number of patients on a unit without appropriate indications and relay this concern to the nurse manager on the unit. The champion takes on the mantel of striving to improve patient safety and encourages the individual HCW's sense of accountability. Some may even have experience in peer-to-peer coaching and addressing just culture, which recognizes that even competent HCWs may make mistakes and should not be accountable for system failings, but they do not tolerate reckless behavior.
We suggest that all hospital teams include nurse and physician champions (Table 3). The nurse champion explains the project details to the team members and ensures that the staff is educated about CAUTI and appropriate indications for catheter use. The nurse champion facilitates the use of teamwork tools and supports the integration of a CUSP into the daily workflow at the unit level. The physician champion is chosen based on an interest in preventing harm related to the urinary catheter. The role of the physician champion is to connect with other physicians, promoting the multidisciplinary support of peers to the project. Infection preventionists play a significant role in supporting the work, highlighting the infectious risks, and helping with data collection related to CAUTI. The team also includes bedside nurses and, in some hospitals, nursing assistants. Daily nursing rounds are used to help identify patients with catheters and trigger the question: “Is the catheter needed?” The unit team learns from each case presented during rounds to incorporate catheter evaluation as a routine daily task. The goal is to have the bedside nurses own the daily process to evaluating the catheter.
Additionally, the team uses process and outcome data to identify areas that require further improvement. For example, the team assesses the frequency of using urinary catheters without appropriate indications and implements solutions. Regular evaluation of CAUTI events and rates help provide the teams with feedback on their performance and highlights that CAUTI prevention is a continuing priority.
Table 3Key roles of the team members responsible for reducing CAUTI
For successful results, hospital teams need to have a plan to sustain the improvements. Sustainability is achieved if the improvements are maintained or augmented after implementation; for CAUTI prevention, the improvements are reflected in an increase in appropriate catheter use and a reduction in CAUTI events. Sustainability is promoted when the daily evaluation of urinary catheter use and necessity becomes integrated into the HCW's routine, and the hospital has built capacity for continued support.
Integration of urinary catheter assessment into the daily workflow of nurses helps make it a routine task. It also ensures accountability and commitment from the HCW. The program champions continue to play a significant role in reinforcing the importance of appropriate use and care of the catheter, keeping it as a priority. However, reliance only on champions can undermine the sustainability of the processes, either with the loss of the champion or the lack of delegation to other essential members involved in the work.
Continued periodic evaluation and feedback are important to identify any gaps and refine the process. Modifications of the program may occur with time, based on new evidence.
Identifying solutions that address data burden through data mining or sharing resources between disciplines may help reduce the perceived difficulties related to the work. Finally, involving different hospital units may reap global benefits. For example, addressing urinary catheter placement in the ED leads to a reduction in urinary catheter use hospital-wide.
Multidisciplinary and multidepartmental efforts may include the ED, intensive care units, and ORs. Because urinary catheters travel with patients from admission in the ED, to their stay in the intensive care unit or during their surgery, and back to their care in the nonintensive care unit areas, collaboration between the different hospital units and disciplines is important to achieve successful results (Fig 3).
Fig 3How different interventions affect urinary catheter use on the non-ICUs. Abbreviations: ICU, intensive care unit; PACU, postanesthesia care unit; OR, operating room; ED, emergency department.
Although reducing the risk of CAUTI involves a collaborative effort between different stakeholders, engaging HCWs at the hospital and unit level is critical. Although national engagement is helpful, perhaps the most important ingredient of success is engaging HCWs at the unit and hospital level, thereby providing the ability to implement changes that will enhance patient safety.
References
Meddings J.
Rogers M.A.
Krein S.L.
Fakih M.G.
Olmsted R.N.
Saint S.
Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review.
Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America.
Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010.
Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
Centers for Medicare and Medicaid Services (CMS), HHS
Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and Fiscal Year 2014 rates; quality reporting requirements for specific providers; hospital conditions of participation; payment policies related to patient status. Final rules.
Name of AHRQ-funded HAI project: Demonstration of CUSP to Reduce Catheter-associated Urinary Tract Infections (CAUTI).
Funding/Support: This project was supported by a contract from the Agency for Healthcare Research and Quality HHSA290201000025I / HHSA29032001T .
Publication of this article was supported by the Agency for Healthcare Research and Quality (AHRQ).
Conflicts of interest: Dr Fakih receives support for the development and implementation of the “On the CUSP: Stop CAUTI” initiative serving as a member of the National Leadership Team and from the Ascension Health Hospital Engagement Network effort to prevent healthcare-associated infections and Michigan Health & Hospital Association Hospital Engagement Network to reduce CAUTI. Dr Saint has received numerous honoraria and speaking fees from academic medical centers, hospitals, group-purchasing organizations (eg, Premier, Veterans Health Administration), specialty societies, state-based hospital associations, and nonprofit foundations (eg, Michigan Health and Hospital Association, Institute for Healthcare Improvement) for lectures about catheter-associated urinary tract infection, implementing change, and leadership. This project was funded through a contract from the Agency for Healthcare Research & Quality to the Health Research & Educational Trust . No other potential conflicts of interest are noted.
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