PSQH Innovation Awards Winner: Ascension St. Mary’s Revamps Processes to Reverse HAI Trend

By Jay Kumar

Editor’s note: The fifth annual PSQH Innovation Awards recognize healthcare organizations who overcame patient safety or quality improvement challenges. In this article, we highlight the winning submission selected from Ascension St. Mary’s Hospital in Saginaw, Michigan. 

After noticing that efforts to curtail hospital-acquired infections (HAI) weren’t effective, leaders at Ascension St. Mary’s Hospital in Saginaw, Michigan, realized that changes were needed to turn the tide.

The challenge

In Ascension-St. Mary’s award submission, Karen Vargas, regional director of Quality, Patient Safety, and Regulatory Compliance, wrote that in the first and second quarters of 2022, the hospital noted an increased incidence/upward trend of National Health Safety Network (NHSN)-reportable HAIs: Catheter-associated urinary tract infections (CAUTI), Central line-associated bloodstream infections (CLABSI),Methicillin-resistant Staphylococcus aureus (MRSA), and Clostridioides difficile (C. diff). It was recognized that a variety of disciplines and departments were working to improve HAI outcomes (Nursing, Infection Control, Medical Staff, Education, Lean, Quality), yet improvement efforts were siloed. There was limited integration of improvement efforts amongst the departments resulting in a perceived lack of ownership, accountability, responsibility and urgency; subsequently, improved patient outcomes were not being realized.

“A Quality-HAI Team with a defined quality improvement process was proposed (noting quality improvement is the framework used to systematically improve care with quality improvement seeking to standardize structure and process to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations),” Vargas wrote.

The Quality-HAI Team drafted a charter, was provided with support by the Hospital Executive team, the hospitalwide Patient Safety & Quality Committee team, and the team was deployed in June 2022. The objective and goals of the Quality HAI Team, per the charter, was to strategically align improvement activities to increase engagement and accountability of all stakeholders to reduce incidence of HAIs by 30% by the end of CY 2022. The Quality HAI Team, once formed, established a structure/framework via the development of a HAI Reduction Standard Operating Procedures (SOP) document, with the purpose of the document to strategically align and engage all stakeholders to increase accountability and reduce incidence of HAIs.

“From the SOP document, which is continually updated as processes are further established and policies/practices are further aligned with best practices, processes are developed to deliver upon the vision of 1. retrospective case reviews to analyze HAIs as they occur to identify existing clinical systems opportunities and correct them using educating and the auditing cycle (set goals, educate on best practices, monitor for compliance, review results and opportunities, and share findings regularly), and 2. proactive prevention: standardized education and training of all frontline staff on appropriate indications, insertion, maintenance, hygiene of lines, catheter, and equipment (second stage),” wrote Vargas

The solution

The team was able to create a process workflow to address HAIs and the results have been impressive.

“The Quality HAI Team has been able to accomplish much without additional resources and limited staffing given the post-COVID staffing and clinical environment,” Vargas wrote. “Given the work at hand impacts patient outcomes, the existing leaders and clinical team were motivated to accept additional responsibilities to drive the outcomes.”

The key steps in implementation were as follows:

  • Identify the problem
  • Identify key stakeholders
  • Request chartered team through the Hospital Patient Safety & Quality Committee (PSQ)
  • Create Quality HAI Standard Operating Procedures
  • Identify Physician and Nursing HAI champions
  • Create project teams for each HAI lead by designated Champions
  • For new HAI events, create a sense of urgency by deploying an “immediate clinical review” pull up meeting the next business day (like a “code blue” event)
  • Post immediate clinical review; conduct a deep dive of the case with physicians and clinicians
  • Identiy opportunities from the deep dive referred to project team or administrative/medical staff/peer review as indicated to implement
  • Conduct monthly meetings to aggregate all work, projects and metrics

The team’s efforts have resulted in the following actual/FYE projected reduction in the total number of HAIs from FY 2022 to FY 2023:

  • CLABSI: 71% reduction
  • MRSA: 75% reduction
  • CAUTI: 50% reduction
  • C. diff: 67% reduction


Ascension St. Mary’s continued to deal with challenges as the solution was rolled out.

“Challenges continue to be resources for education to deploy best practices given limited resources internally as well as externally with product vendors,” Vargas wrote. Another hurdle was maintaining provider/clinical engagement given competing priorities with limited staff and increased requests for deliverables, meetings, and accountabilities.

“As the work has evolved with immediate case reviews with new cases, it has been found that over time, the initial urgency has been established to convey all new events as the highest priority,” she added. “However, it has been found that the greatest yield comes when new cases can be reviewed via a deep dive evaluation of the case. Subsequently, as the model has evolved, working to progress from still establishing the urgency with immediate notifications of new events, but giving ample time with focus on deep dive analysis. Additionally, working on identifying trends and/or case commonality. Ultimately, moving from a reactionary model to a proactive/sustainability model.”

Vargas noted that the process Ascension St. Mary’s created was the key to the project’s success.

“Quality improvement requires a standardized structure and process to reduce variation to achieve predictable results and improve outcomes,” she wrote. “Healthcare organizations are complex systems with all working to optimize patient care and outcomes, but strategically planning the work and working the plan with a coordinated team approach helps to optimize outcomes.”

Honorable mentions

The following submissions were selected as honorable mentions:

Nicklaus Children’s Hospital, Miami

Nicklaus Children’s is a free-standing tertiary care pediatric hospital that provides acute care to medically complex children from Florida and beyond. The hospital was seeing increased incidents of agitation and aggression in pediatric patients with Autism Spectrum Disorder (ASD), who were triggered by multiple invasive tests and procedures, frequent visits, and prolonged discomfort. Staff surveys and feedback found a high level of anxiety and fear for safety when providing care to patients during behavioral events. An interdisciplinary task force created Nicklaus’ Adaptive Care Program to increase the quality of care for neurodivergent patients and those with behavioral or communication vulnerabilities. A new alert response, Code Bear, was created to differentiate between patient behavioral events and staff or visitor aggression. After implementation in 2020, the hospital has seen employee injuries by patients during Code Bear incidents from Q3 2020 to Q2 2022 dramatically decrease to 8%, compared to 43% prior to implementation in the first two quarters of 2020.

Northwell Health, Port Jefferson, NY

Mather Hospital Northwell Health had implemented a coordinated response to patient falls activated by an overhead page known as a “Code Fall” in October 2017, which sent a multidisciplinary team to respond to the incident. But a review of team member injuries from implementation of Code Fall in 2017 through February 2019 found a high percentage of injuries associated with fall prevention or subsequent recovery from the floor (43% in 2017, 50% in 2018, 66% in Jan./Feb. 2019). The hospital developed an algorithm to guide safe recovery methods for patients and team members after a fall, created a Code Fall Response Cart (similar to a crash cart) with easily accessible patient handling equipment, and began initial and ongoing education of all potential Code Fall responders on the algorithm and cart.Team member safety has improved in multiple ways since implementation in March 2019, including the near elimination of manual lifting as a floor recovery method. The team members are following better practices of safe patient handling, improving patient care and protecting the team members.