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Non-ventilator health care-associated pneumonia (NV-HAP): Taking action to improve NV-HAP outcomes

      As more evidence about nonventilator health care-associated pneumonia prevention research emerges, health care organizations need to be prepared to review the recommendations and develop plans to translate that evidence into practice. This section provides guidance on implementation and change strategies. Highlights include expectations of accountability from the leadership level to the frontline staff, the “Four E” change model (engage, educate, execute, and evaluate), the role of champions, the Plan, Do, Check, Act cycle and other strategies, tools and checklists to ensure successful implementation of evidence- based practices.

      Key Words

      Improving patient safety and quality of care is a national imperative. Since the release of the Institute of Medicine's landmark report To Err is Human in 2000, there has been a growing emphasis on preventing unnecessary risks and harm to patients. The report estimated that nearly 98,000 hospitalized patients died each year in the United States as a result of preventable medical errors. This is the equivalent to a 747-airliner crashing every day, killing all on board.
      Institute of Medicine (US) Committee on Quality of Health Care in America
      The report's authors recommended that health care organizations focus on the process of the delivery care and adoption of a safety culture incorporating principles and systems that improve the reliability of care, standardize clinical practices, improve the safety of working conditions, and continuously monitor patient safety outcomes. A culture of safety recognizes risk, addresses safety events with a blame-free approach, and engages frontline staff in the identification of safety concerns and development of solutions.
      As discussed throughout this guide, nonventilator health care-associated pneumonia (NV-HAP) is a preventable event that that occurs with great frequency, leading to increased morbidity, mortality, and health care costs. Health care organizations must carefully assess both clinical and safety culture–related factors that lead to failures in NV-HAP prevention. Health care organizations should use a structured quality improvement approach that not only identifies gaps in their current processes but also supports multidisciplinary solutions and plans to sustain prevention efforts.
      As more evidence about NV-HAP prevention research emerges, health care organizations need to be prepared to review the recommendations and develop plans to translate that evidence into practice. In most organizations, improving NV-HAP-related outcomes will likely require practice changes, such as instituting an oral care protocol and ensuring that it is followed. Challenges related to adopting practice changes include lack of clinical staff knowledge about the issue, lack of unit-level leadership to support the change, and insufficient time and resources, both clinical and educational, to effectively support implementation of the practices.
      • Curtis K
      • Fry M
      • Shaban RZ
      • Considine J
      Translating research findings to clinical nursing practice.
      Among the obstacles to obtaining support and resources for NV-HAP programs is that the condition is not part of mandatory this health care-associated infection reporting in most states.
      When implementing evidence-based interventions, consideration must be given to the current status of existing resources, staff knowledge, institution/facility culture, and the level of commitment of stakeholders.
      • Pronovost PJ
      • Berenholtz SM
      • Goeschel CA
      • et al.
      Creating high reliability in health care organizations.
      Expectations of accountability from the leadership level to the frontline staff helps ensure the successful implementation of new practices. The “Four E” change model (engage, educate, execute, and evaluate) can guide quality improvement teams as they organize their improvement efforts.
      • Klompas M
      • Branson R
      • Eichenwald EC
      • et al.
      Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update.

      Engagement

      Engaging stakeholders in a crucial first step in improving patient care. Both leaders and frontline staff need to “buy in” to the idea that (1) a problem exists, and (2) the efforts that they are being asked to support will result in meaningful change.

      Multidisciplinary teamwork

      Bringing together a multidisciplinary team to address NV-HAP is a priority. This team should meet regularly to review data, identify opportunities for improvement, and develop improvement plans, including new protocols or policies. When building this team, consider including those health care workers and ancillary staff who play a role in the care of patients at risk for developing NV-HAP as well as staff who are knowledgeable in data analytics and performance improvement methodology. Team members should include representation from the following disciplines and departments:
      • Nursing
      • Clinical education
      • Education
      • Infection prevention
      • Medicine and laboratory services
      • Respiratory therapy
      • Physical therapy
      • Speech pathology
      • Nutrition
      • Pharmacy, including someone who participates in the antibiotic stewardship program
      • Patient and family support
      • Performance improvement
      • Data analysis
      Other team members who may be included on an ad hoc basis are representatives from information technology, health information management (coding), and materials management. These departments may be involved in electronic medical record (EMR) modifications, data collection and case identification, and patient care product changes, respectively.

      Champions for improvement

      An important aspect of engagement is identifying champions who will serve as leaders among their peers and drive the NV-HAP improvement efforts at the bedside. Champions can be nurses, nursing assistants, physicians, respiratory therapists, or other individuals who have knowledge of both clinical and quality improvement aspects of NV-HAP prevention and a passion for patient safety. Champions are responsible for modeling prevention practices through their behavior and actions, advocating for others to implement best practices, and offering solution-oriented support when challenges arise.
      • Saint S
      • Krein SL
      • Stock W
      Preventing Hospital Infections: Real-World Problems, Realistic Solutions.
      Champions for NV-HAP prevention are crucial to engage staff during the initial phases of an improvement project, but they also serve an important role in sustaining change and improvement over time. They can help orient new staff to pneumonia prevention protocols and processes, provide insightful feedback to the NV-HAP prevention team during periods of process review, and identify opportunities for ongoing improvement.

      Leadership engagement

      Leadership support of NV-HAP prevention strategies is absolutely necessary for teams to secure the needed time and resources to implement changes. One way to engage senior leaders is to show the financial value of pneumonia prevention efforts. Cost-effectiveness models are used frequently by both large- and small-scale quality improvement programs to demonstrate the impact of harm prevention actions and drive continued investment in prevention activities.
      • Dick AW
      • Perencevich EN
      • Pogorzelska-Maziarz M
      • Zwanziger J
      • Larson EL
      • Stone PW
      A decade of investment in infection prevention: a cost-effectiveness analysis.
      For example, Talley and colleagues investigated cost savings after implementing an oral care protocol as part of a NV-HAP prevention study at St. John Medical Center in Bixby, Oklahoma, and they demonstrated that the change prevented 5 cases of pneumonia. Minus the cost of the new oral care products, this change saved the organization $195,400. By showing the return on investment, the NV-HAP prevention team illustrated to leadership that investing in the resources to support this type of improvement program saved lives and dollars.
      • Talley L
      • Lamb J
      • Harl J
      • Lorenz H
      • Green L
      HAP prevention for nonventilated adults in acute care: can a structured oral care program reduce infection incidence?.

      Patient and family engagement

      The Institute for Patient and Family Centered Care defines patient- and family‐centered care as “an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families.”

      Institute for Patient and Family Centered Care. Patient- and family-centered care. Available at: https://www.ipfcc.org/about/pfcc.html. Accessed November 3, 2019.

      NV-HAP prevention teams can engage patients and families in the following ways:
      • Ask patients and families about their preferences and health care choices related to the prevention of pneumonia.
      • Provide them with information about NV-HAP protocols and care practices.
      • Include them in shared decision-making about the implementation of pneumonia prevention practices, including oral care preferences.
      • Collaborate with them to set mutually agreed-upon goals that will lead to positive health outcomes and avoidance of pneumonia.
      Patient and family advisors can provide valuable support to the NV-HAP prevention team's efforts. A patient and family advisor is an individual with personal experience as a patient or family member of a patient who has partnered with the health care organization to provide insight based on that experience.

      Institute for Patient and Family Centered Care. Patient and family advisors. Available at:https://www.ipfcc.org/bestpractices/patient-and-family-advisors.html. Accessed November 3, 2019.

      An advisor can meet with patients who are at increased risk of developing pneumonia and their families and help provide reinforcement and education about prevention practices. If questions or concerns emerge during their discussions with patients and families, advisors can bring these issues back to health care staff. Thus, they serve as an important bridge to connect patients and families to the health care team.

      Education

      Providing education to staff regarding different aspects of a NV-HAP improvement project is an essential step in preparing them for practice changes. Staff need to clearly understand how NV-HAP can develop and which patients are at highest risk. Additionally, as new protocols, processes, documentation, or supplies and equipment are introduced to the clinical setting, staff must be trained on how to use them safely and effectively.

      Educational needs assessment

      The first step in designing an education and training plan is to conduct an educational needs assessment.
      • Gruppen LD
      • Mangrulkar RS
      • Kolars JC
      The promise of competency-based education in the health professions for improving global health.
      Working collaboratively with the clinical educator, the NV-HAP prevention team will review sources of information that identify where gaps in skills and knowledge may exist. These sources may include the following:
      • High-risk interventions based on a risk assessment, for example-aspiration precautions for stroke patients
      • Results of quality improvement studies and root-cause analysis findings from review of NV-HAP cases
      • Design of new EMR documentation (eg, nurse documentation of the oral care protocol)
      • Implementation of new NV-HAP prevention protocols, such as the oral care protocol or early mobility protocol
      • Introduction of new equipment or products, such as toothbrushing supplies or suction equipment
      • Federal or state requirements, including mandatory reporting of pneumonia through the National Healthcare Safety Network
      • Accrediting body requirements, such as hand hygiene or transmission-based precautions protocols.
      While these sources provide objective examples that may be the focus of educational opportunities, it is important to also seek feedback directly from the frontline staff who manage the care of patients at risk for pneumonia. Staff feedback can provide useful insights and is an effective way to engage staff in identifying problems and creating solutions.
      Developed through the Comprehensive Unit-based Safety Program model, the staff safety assessment is a simple way for quality improvement leaders to keep current on the safety issues that frontline staff identify as priorities.

      Agency for Healthcare Research and Quality. Staff safety assessment: CUSP toolkit. Available at: https://www.ahrq.gov/hai/cusp/toolkit/staff-safety-assessment.html. Published December 2012. Accessed November 3, 2019.

      The assessment poses 2 questions:
      • How will the next patient on our unit develop NV-HAP?
      • What can we do to prevent that NV-HAP case from happening?
      By asking these 2 simple questions, the NV-HAP prevention team can gain firsthand knowledge of the issues that concern the frontline staff the most. They may also identify safety concerns that were not identified through other needs assessments. The following is an example of an actionable concern that a nurse's aide may voice about the oral care protocol:
      • Patients hate the toothbrushes we have. They complain the bristles are too hard and always fall off when they brush. Many times, my patients just refuse to brush their teeth because of the cheap toothbrushes we have. I would suggest that we buy better-quality toothbrushes, similar to what our patients would use at home. Then, if we encourage them to brush their teeth after all meals because it is important to their health, we might be able to prevent more cases of pneumonia.
      An exercise like this is valuable to the NV-HAP prevention team because it engages a staff member to identify both a gap and a solution, and it brings a simple, yet important safety concern to the attention of the team that can drive changes.

      Competency-based training

      Based on what they discover while reviewing different information sources, clinical educators can prioritize which interventions merit the most focused amount of education. Once the topics of focus have been identified and prioritized, the clinical educator, in consultation with the NV-HAP prevention team, must plan for the trainings. Using a competency-based training approach to developing educational objectives, content, and activities, the educator can tailor training methods to address the specific needs of different types of learners and develop strategies to verify learner competence after training.
      • Gruppen LD
      • Mangrulkar RS
      • Kolars JC
      The promise of competency-based education in the health professions for improving global health.
      Considering the educational topic and the staff who will be required to demonstrate the skill competence, trainings should be organized using a structured approach. The Miller pyramid breaks down clinical competence into the following 4 categories:
      • Miller GE
      The assessment of clinical skills/competence/performance.
      • Knowing (knowledge): The learner gained a basic level of knowledge of the content.
      • Knows how (competence): The learner understands how to apply the new knowledge.
      • Shows how (performance): The learner can demonstrate the skill.
      • Does (action): The learner can independently perform the skill in practice.
      When training staff on NV-HAP prevention strategies, different learning competencies will require different learning environments. For example, if you are teaching new nurses about the pathophysiology of pneumonia and the objective is to increase their knowledge level, an online learning platform with a pretest and posttest is sufficient. If you are teaching a group of nursing assistants how to perform denture care, you will need a learning environment in which the space and equipment are available so learners can perform this task while being evaluated. To verify that staff can perform skills independently in practice, educators should create a competency skill checklist that can be used as part of a clinical observation process at the bedside. For example, a competency skill checklist might be used to assess a speech language pathologist conducting a speech and swallow evaluation on a patient recovering from a stroke.
      Some aspects of NV-HAP prevention require a multidisciplinary approach, including daily rounding and assessment of pneumonia risk. Interprofessional learning can prepare clinical teams to work together to achieve NV-HAP prevention goals.
      • Frenk J
      • Chen L
      • Bhutta ZA
      • et al.
      Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.
      Table 1 presents examples of learning activities that can promote an interdisciplinary approach to NV-HAP prevention.
      Table 1Selected learning activities for interdisciplinary NV-HAP prevention
      Learning activitySample learning objectives
      Simulation trainingParticipants will be able to demonstrate how to collaboratively conduct an NV-HAP risk assessment for a patient recovering from cerebral vascular accident.
      Unit-based “just in time” trainingParticipants will be able to identify indications for a new oral care product just stocked on the unit.
      Discussion groupsParticipants will be able to discuss proposed changes to the electronic medical record's multidisciplinary documentation section for oral care.
      Poster presentationsParticipants will be able to share department-specific NV-HAP improvement strategies and outcome results.

      Execution

      Successful execution of a health care quality improvement program includes standardizing care processes where possible.
      • Klompas M
      • Branson R
      • Eichenwald EC
      • et al.
      Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update.
      Standardization can occur through the development of NV-HAP protocols and bundles similar to those that have been used to improve care around other high-risk conditions, including sepsis and central line–associated bloodstream infections.

      Developing bundles

      According to the Institute for Healthcare Improvement (IHI), a bundle is a “small set of evidence-based interventions for a defined patient segment/population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually.”
      • Resar R
      • Griffin FA
      • Haraden C
      • Nolan TW
      Using Care Bundles to Improve Health Care Quality.
      (p2)
      IHI provides a simple framework to follow when developing bundles:
      • Resar R
      • Griffin FA
      • Haraden C
      • Nolan TW
      Using Care Bundles to Improve Health Care Quality.
      • Limit bundles to 3-5 interventions.
      • Each bundle element should be independent of the others.
      • The bundle is targeted toward a defined patient population.
      • The multidisciplinary care team develops the bundle.
      • Bundle elements should be descriptive rather than prescriptive, allowing for flexibility in application based on clinical judgment.
      • Compliance with bundles should be audited.
      For NV-HAP prevention, bundle elements should focus on basic care strategies, including promoting oral hygiene, reducing risk of aspiration, and promoting the patient's own natural defense systems again pneumonia (see Best Practices for Prevention of NV-HAP). Most evidence points to oral care as the most modifiable risk factor; additionally, there is limited evidence showing that interventions around dysphagia screening and early mobility may also be effective.
      • Mitchell BG
      • Russo PL
      • Cheng AC
      • et al.
      Strategies to reduce non-ventilator-associated hospital-acquired pneumonia: a systematic review.
      Prevention teams considering implementation of NV-HAP prevention bundled strategies can stratify their approach by the patient risk level. There are interventions aimed at all patients, patients with increased risk of aspiration, and patients at risk of pneumonia due to weakened host defenses.

      NV-HAP prevention oral care bundle for all patients (self-care)

      Implement an oral care protocol that indicates brushing or denture care 2-4 times daily:
      • Brush for 1-2 minutes with a soft-bristled toothbrush and toothpaste with fluoride (sodium bicarbonate preferred).
      • Rinse with antiseptic, alcohol-free oral rinse.
      • Apply mouth and lip moisturizer (non-petroleum-based).
      • If patient has dentures, remove and soak them in a denture cleaning solution for the time frame recommended by the solution manufacturer, and brush gums and mouth.

      NV-HAP prevention bundle for patients at increased risk for aspiration

      This bundle would be used, for example, for stroke or mechanically ventilated patients.
      • For nonventilated patients: Oral care protocol that indicates brushing for 1-2 minutes with a suction toothbrush 2-4 times daily.
      • For ventilated patients: Oral care protocol that indicates brushing/swabbing for 1-2 minutes with an ICU suction toothbrush/swab every 4 hours or up to 6 times daily, with optional chlorhexidine 0.12% every 12 hours. Extubate when mechanical ventilation is no longer needed.
      • Perform swallow screens for patients at risk for dysphagia.
      • Elevate head of bed 30°-45°.
      • If patient is receiving enteral nutrition, follow tube feeding protocols.

      NV-HAP prevention bundle for patients with compromised host defenses

      This bundle would be used, for example, for postoperative patients:
      • Implement oral care protocol (see NV-HAP Prevention Oral Care Bundle for All Patients).
      • Early mobilization: Start mobilization early and advance as tolerated.
      • Promote lung expansion by encouraging patients to take deep breaths and cough or perform incentive spirometry.
      • Provide adequate nutrition and ensure serum glucose is in target range.
      • Provide stress ulcer prophylaxis(only if indicated).

      Bundle compliance

      Once bundles are implemented, NV-HAP teams should conduct regular audits of bundle compliance. This can include direct observation of bundle interventions and chart review to verify that interventions are done and documented. It is important that frontline staff are provided feedback on their performance so they can improve their practices when indicated. Figure 1 is an example of basic audit tool to measure oral care compliance.
      Fig 1
      Fig 1Sample audit tool for NV-HAP oral care bundle compliance.

      Evaluate

      To measure the impact of NV-HAP prevention efforts, quality improvement teams must identify metrics that can accurately measure the intended outcomes. Data that support the effectiveness of the intervention help engage leaders and frontline staff, can show the financial impact of the initiative, and can drive ongoing sustainment of the improvement activity.
      When considering NV-HAP data, teams should review current published literature to determine which measures and data collection methods are most valid, reliable, and suitable for their needs. Possible outcome measures include NV-HAP incidence rates, lengths of stay, and mortality rates. While published data show that NV-HAP is a major issue, a single, valid standardized definition is not established. As evidence emerges, new NV-HAP surveillance measures are being tested, but many still require validation.
      • Ji W
      • McKenna C
      • Ochoa A
      • et al.
      Development and assessment of objective surveillance definitions for nonventilator hospital-acquired pneumonia.
      Accessing data from different sources can help provide a broader perspective of the issue being studied.
      Agency for Healthcare Research and Quality
      Practice Facilitation Handbook. Module 7: Measuring and Benchmarking Clinical Performance.
      NV-HAP data components can be collected from several sources, including laboratory test results, clinical documentation, imaging studies, and administrative coding data. These data elements have been used to identify cases based on established surveillance criteria.
      To determine incidence rates of NV-HAP in multiple hospitals, Baker and Quinn used a combination approach in which they first identified cases with ICD-9-CM diagnosis codes for not present on admission pneumonia and then performed a case review using the 2013 National Healthcare Safety Network surveillance definition of pneumonia. Based on this methodology, they found the NV-HAP incidence rate to be between 0.12 and 2.28 cases per 1,000 patient days in the 21 hospitals that completed the study.
      • Baker D
      • Quinn B
      Hospital Acquired Pneumonia Prevention Initiative-2: incidence of nonventilator hospital-acquired pneumonia in the United States.
      While these results are useful for benchmarking and comparison, these surveillance methods have limitations. For example, the methods may underestimate the number of cases due to inconsistencies in clinical documentation and code assignment, and subjectivity of interpretation of clinical results (eg, radiological studies).
      • Ji W
      • McKenna C
      • Ochoa A
      • et al.
      Development and assessment of objective surveillance definitions for nonventilator hospital-acquired pneumonia.
      As noted in The Infecton Preventionist's Role in Identifying NV-HAP of this supplement, a recent publication by Ji et al have proposed a new, more objective NV-HAP surveillance method that could provide a more efficient form of surveillance by capturing key elements from the EMR.
      • Ji W
      • McKenna C
      • Ochoa A
      • et al.
      Development and assessment of objective surveillance definitions for nonventilator hospital-acquired pneumonia.
      Ji and colleagues’ 3-year cohort study of 2 tertiary referral facilities and 2 community hospitals analyzed EMR data for more than 300,000 admitted patients, using a case definition for NV-HAP based on 5 clinical indicators:
      • Ji W
      • McKenna C
      • Ochoa A
      • et al.
      Development and assessment of objective surveillance definitions for nonventilator hospital-acquired pneumonia.
      • Worsening oxygenation
      • Greater than 3 days of a new antibiotic administration
      • Fever
      • Abnormal white blood cell count (less than 4,000/mcL or greater than 12,000/mcL)
      • Performance of chest imaging
      The investigators found (1) NV-HAP incidence rates of 0.6 cases per 100 admissions, (2) length of time to discharge doubled compared to non-NV-HAP patients, and (3) a crude mortality rate of 27.7%, showing patients with NV-HAP were 5-6 times more likely to die than non-NV-HAP patients. The researchers noted that their new method produced results that were similar to previous studies, and opportunities remain to improve the specificity and sensitively of the approach.
      • Ji W
      • McKenna C
      • Ochoa A
      • et al.
      Development and assessment of objective surveillance definitions for nonventilator hospital-acquired pneumonia.
      By using a similar approach to either the method used by Baker and Quinn
      • Baker D
      • Quinn B
      Hospital Acquired Pneumonia Prevention Initiative-2: incidence of nonventilator hospital-acquired pneumonia in the United States.
      or that of Ji and associates,
      • Ji W
      • McKenna C
      • Ochoa A
      • et al.
      Development and assessment of objective surveillance definitions for nonventilator hospital-acquired pneumonia.
      NV-HAP prevention teams can determine important data trends that could create baseline measurements and help set improvement goals for their pneumonia prevention activities.

      Using data to drive improvement

      Data are powerful tools to drive improvement in the clinical setting. Data elements can include both clinical and financial measures, such as infection rates, mortality rates, cost of treatment, and lengths of stay. Once the NV-HAP prevention team has conducted surveillance to demonstrate the baseline burden and impact, they may address 3 questions:
      • What aspect of NV-HAP prevention are we trying to accomplish?
      • How will we know if the change results in success?
      • What is the change that will lead to a successful reduction in NV-HAP?
      These questions and the resulting answers will guide teams to focus on a specific area of improvement.

      The PDSA model

      A valuable tool for data-driven improvement is the Plan-Do-Study-Act (PDSA) model created by IHI as part of its Quality Improvement Model; it is a framework that allows quality improvement teams to rapidly test change on a small scale and make modifications as indicated.

      Institute for Healthcare Improvement. Science of improvement: testing changes. Available at: http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx. Accessed November 4, 2019.

      It is important to plan ahead when initiating a PDSA project, and following the IHI model will allow a thoughtful and well-executed approach:
      • Plan: The planning stage is about defining the “who, what, when, and how.” For example, if the team is trying to reduce the incidence of NV-HAP through the implementation of an oral care protocol, team members would need to clearly outline how they plan to achieve that, including designing and getting approval for the intervention itself. They should determine which patient population will be the subject of the test of change, which staff will participate, when the test will occur, and for what duration. To allow for greater control, the test of change should be conducted on a small scale—for example, it might include 2 staff members who will test the change on 2 patients over 3 days. Finally, the team should define the measure of success and make a prediction of what outcome the change will create.
      • Do: This is the action phase of PDSA. Quality improvement teams will prepare the staff for the change, including providing education and opportunities to ask questions. If there are new protocols, products, equipment, or documentation involved, staff should be trained beforehand. If there is a new process that will require measurement, an audit or case review tool should be created ahead of time. Once the necessary preparation is completed, the small test of change can be initiated.
      • Study: While the test of change is occurring, it is important to monitor the impact. This includes measuring outcomes as well as monitoring for process compliance. If a new oral care protocol is initiated, the level of compliance with the components of the protocol should be reviewed. Teams can compare the results to the predicted outcomes and available baseline data. An important part of this step is analyzing the results to determine which factors and variables had a positive or negative impact on the test. Compare the outcomes identified to predictions made in the “plan” phase.
      • Act: Once the test of change has concluded and the data have been studied, there comes a decision point. Based on the results, the team must decide to adopt, adapt, or abandon the change. If the results confirm successful implementation, adopting the change and planning for its further dissemination would be appropriate. If the results show that a modification to the test may improve the outcomes, the team should adapt the process and conduct an additional test of change. If the test results in an undesirable outcome and the team feels that modifications will not improve the intervention, the change idea may be abandoned.
      For example, when implementing an oral care protocol, the NV-HAP prevention team might consider the change ideas outlined in Table 2,

      Institute for Healthcare Improvement. Basic improvement methodology. Available at:http://www.ihi.org/education/IHIOpenSchool/Courses/Documents/QI102_lecture.pptx. Accessed November 4, 2019.

      and then proceed through the PDSA steps.
      Table 2Change ideas for implementation of an oral care protocol
      What are we trying to accomplish?Change ideas
      Improve workflow.Provide easy access to complete oral care supply kits.
      Optimize inventory.Ensure stock levels for oral care supplies are maintained.
      Change the work environment.Provide competency-based training to all staff responsible for oral care.
      Manage variation.Oral care policy is evidence-based and aligns with current guidelines.
      Design systems to prevent errors.Oral care protocol is readily accessible to clinical staff.

      PDSA example

      To further illustrate how the PDSA cycle works, let's consider an example of an NV-HAP prevention team instituting a new early-mobility protocol for postoperative patients. As part of its annual infection prevention risk assessment, General Hospital infection prevention staff determined that the organization's NV-HAP incidence rate had more than doubled in the past 2 years. Based on this information, the leadership of the hospital convened a NV-HAP prevention team to address the issue. Upon further review of data at the unit level, the team determined the clinical area representing the greatest risk was the surgical ward, with most cases of NV-HAP developing postoperatively in elderly general surgery patients. The team conducted in-depth chart reviews of all patients that developed pneumonia postoperatively.
      A theme that emerged across the cases was lack of early mobility. The team noted insufficient coordination and communication between nursing and physical therapy, with many patients not being assessed or mobilized on a consistent daily basis. The NV-HAP team concluded that a protocol was needed to standardize care for mobilizing postoperative patients. A multidisciplinary team was then formed to develop an early-mobility protocol. Figure 2 shows a PDSA worksheet in which the team documented the steps they took when they initiated the protocol during the testing phase.
      Fig 2
      Fig 2Example of a PDSA worksheet for an early-mobility protocol.
      Fig 2
      Fig 2Example of a PDSA worksheet for an early-mobility protocol.
      As you can see from this example, changes to practice can be challenging to implement. NV-HAP prevention teams can build a strong pneumonia prevention program by leveraging a framework for improvement that includes robust data collection methods and a quality improvement approach that supports incremental implementation and test of change.
      Key points
      • A structured quality improvement approach to NV-HAP prevention will not only identify gaps in current processes but also support multidisciplinary solutions and plans to sustain prevention efforts.
      • The “Four E” change model (engage, educate, execute, and evaluate) can guide quality improvement teams as they organize their improvement efforts.
      • All affected parties—including clinicians, champions for improvement, leaders, and parents and families—must be engaged in improvement strategies.
      • Effective staff education begins with an educational needs assessment and focuses on competency-based training.
      • Successful execution of the quality improvement program will standardize care processes where possible through protocols and prevention bundles.
      • NV-HAP prevention programs should use data to develop and test their action plans. The PDSA model is a useful tool for these endeavors.

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