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RUNNING HEAD: Quality Improvement Project

Quality Improvement Project

Lillian Facka

Servant Leadership

Ann Pryor RN, MS, ANP


“I Pledge”

Quality Improvement Project Identification

Vascular access is crucial in the hospital setting. While it is an invasive way to give

medicine, it guarantees receival and prevents respiratory complications such as aspiration

pneumonia. Often times, a peripheral IV catheter is placed. However, if the patient has poor

vascular access, a central line may be placed. These lines are more invasive, reaching avenues in

the body that lead directly to the heart. Keeping that in mind, it is critical that these lines stay

clean and free of infection.

Unfortunately, impairing the integrity of the skin with an insertion increases the risk of

the patient acquiring an infection. I researched the central line usage at Memorial Regional

Hospital, where I am completing my immersion on Medical Telemetry. This unit sees a high

amount of patients with central lines thus making the data relevant to my clinical practice. A

quality improvement meeting was held for all clinical care leaders in the hospital, of which I was

invited to attend as a student.

During the meeting, we discussed central line utilization and their relationship to

hospital-acquired infections. Several barriers to central line removal included a change in

vascular team management and easier to order a PICC line insertion through vascular team

versus physician insertion. Breaking these elements down, lack of communication and deviation

in care provided appear to be causative factors.

After identifying barriers, we discussed suggestions for infection prevention. Infection

control staff encouraged first line measures before central line insertion to include paging a

phlebotomist to draw labs and insert IVs on a patient with poor vascular integrity. Infection

control staff did recognize that central lines are a vital route for medication and lab access; with

this, they plan to develop central line indications and share them in the physician newsletter.

Nursing education held a high priority: once a PICC line is removed, two peripheral IVs are to be

placed. This promotes PICC line removal due to increased vascular access without penetrating

high volume blood vessels.

Further research was discussed as to how infections manifest. A link was established

between CHG bathing and patients that are self-care. Self-care patients are able to perform

activities of daily living independently. While this promotes normalcy to patients, they may be

performing CHG baths incorrectly, increasing their susceptibility to infection.

Medical Telemetry can hold up to fifteen patients. The unit is regularly full; out of fifteen

patients, two to three have central lines. This presents many opportunities for infections to

manifest; however, we defy the odds by following protocols and keeping central lines clean.

Four Domains of Leadership


Acting as a leader behind this infection prevention process, I have to cultivate and

maintain a level of confidence in the hygiene of central lines within the hospital; meaning I

would fully believe in the CHG bathing process. After having faith in the hygiene process, I

would begin by chart auditing. This would include looking at patient hygiene that has been

completed as well as the integrity of the line in their given flow sheet. Acquiring this data would

lay the groundwork for encouraging and supporting my staff. From there, follow up and

education would be crucial elements to instill a successful implementation of this hygienic



The motivation for this encouragement and follow up is built upon positive patient

outcomes: no infection means less time in the hospital. Skipping a chlorahexadine gluconate

(CHG) bath is not simply cutting a corner to save time, it is placing the patient at risk for

acquiring an infection. As a leader and healthcare provider, we must remember that we are

motivated by the patients and improving their health status. Wiping lines with CHG and the

surrounding skin is vital in the infection prevention process. If there are moments where quality

is lacking, I would encourage cross-checking the behavior of the nurse, encouraging them to

realize how their actions directly relate to the hygiene of the central line.


As a leader, utilizing the hands' domain, I need to set goals, observe my team, and

determine whether or not as a group have we accomplished the goals. Before I establish goals, I

would do my research. The National Center for Biotechnology Information states that it takes 48

hours for a central line to develop an infection if not properly cared for (2018). NCBI also

suggests changing central line tubing every 96 hours, cleaning hubs with disinfectant, and

removing the line when it is no longer needed (2018).

Keeping this data in mind, I would create three goals: properly labeling lines with dates

they were started and when they should be changed, keep CHG at the bedside to promote the use

of disinfectant and establish a checklist with physician input for when central lines should be

removed. I would also encourage my staff by signing a commitment to central line acquired

blood stream infection (CLASBI) free unit; I would lead by example by signing my name.

In addition to setting goals, I would stay informed and provide education on central line

care. The Agency for Healthcare and Research Quality recommends improving safety huddles,

transparent communication regarding CLASBI infections, rewards and recognition for CLASBI

prevention and empower nurses to stop procedures if the established protocol is not followed



Solitude is the primary tool I use for habits. Yoga, meditation, and prayer allow me the

free space to reflect on my actions. I create a safe place to ask myself questions such as what

behavior can I exhibit as a leader to ensure these policies and protocols are carried out properly?

What environment can I create for my team to encourage best practice? What key facts about

central lines should I present to patients to encourage quality self care? Talking and praying with

God will set a humbleness within my soul that will encourage me to act as an instrument as

peace and love.

Model the Way

In order to maintain a new standard, as a leader, I be clear on what my values are.

Sharing my values with my team demonstrates a transparent and trustworthy behavior. It will

take a village of healthcare workers within the multidisciplinary team to execute this new

practice for a CLASBI free unit. While I would not want this group to be policing hospital

employees, I would want them to be a liaison between infection control staff and unit workers;

this would be an effort to fill any gaps that could result in discrepancies ultimately leading to

CLASBI acquisition. This group of leadership would include the pharmacy, physicians, clinical

care leaders, and care management. I see the power in numbers; the more educated our

leadership, the better the health outcomes we will have.

Inspire a Shared Vision

Central line infections affect everyone from the patient to the entire hospital system.

While the hospital may receive poor marks for failing to prevent a CLASBI, it is ultimately the

patient who suffers. Providing compassionate, quality patient care is every healthcare providers’

main goal; this is the behavior I envision as a leader who wants to inspire change. I would love

to hold a meeting for quality improvement on the unit with all staff. This meeting would focus on

the goal of patient outcomes versus how the hospital is affected, creating a goal for the common

good. During this time, I would discuss goals with the staff, when they could best achieve a

positive outcome, and what I can do as a leader to promote their success in delivering patient

care. Circling back to committing to CLASBI prevention, I would remind my staff the impact

they have on patient care by committing to a CLASBI free unit and the exciting possibilities this

could lead to such as staff and hospital recognition.

Challenge the Process

After my initial meeting, I would have meetings with all shifts, days, nights, and

weekends, to follow up on how they are feeling regarding the shared vision for a CLASBI free

unit, creating regular communication internally. This would include looking at patient’s bedside

and seeing what is available for disinfectant, are lines labeled properly, and when the last

disinfectant cleaning was documented; examining the landscape to look for areas of

development. After, I would meet with staff to receive feedback on how the process works for

them within their shifts and if there is anything I can do as a nurse leader to help with

implementation. Additionally, to challenge the process, I would provide evidence and data from

the Joint Commission. The Joint Commission offers helpful resources such as how to conduct

clinical surveillance with central lines, how to insert a central line as well as how to maintain and

remove the line, and what appropriate documentation looks like. I would encourage use of this

data in times when I am not available to act as a leader.

Enable Others to Act

Prevention of CLASBI presence on the unit is a team effort. In order to have

effective team work, everyone from technicians to doctors must be properly informed of

prevention protocol. The Center for Disease Control states my vision as a nurse leader perfectly

“Full engagement between local, state and federal public health agencies and their partners in the

healthcare sector through initiatives such as the prevention collaboratives is vital to sustaining

and extending HAI surveillance and prevention progress” (2016).

As healthcare providers, we must be fully engaged in our patients care. In addition to

staff education, we also must praise the employees on the unit. A great example of this is

Memorial Regional’s Medical Telemetry. After staying free of CLASBIs, the unit received an

award from the infection control department of the hospital, an incredibly high honor that is

difficult to obtain. As a nurse leader, I would be sure to not only educate my team, but praise

them as well.

Encourage the Heart

Similar to enabling others to act, as a nurse leader I have to encourage the hearts of my

team by practicing gratitude and compassion. In order to provoke a sense of trust, I need to know

how each individual team member receives love in a professional environment. This could be

words of affirmation, gifts, or acts of service. I would ask the team to take a professional love

language quiz to help me as a leader to identify what ways I can provide positive feedback. This,

in turn, will help me continue to build up my team in high and low times. I will link victories to

the values of our Bon Secours hospital system: integrity and compassion being of the utmost

importance. In addition, the team has to celebrate each other’s victories as well. This will

develop an appreciation and bond, creating a safe and trusting environment.

Professional Practice Implications

The implications for profession practice are the need to improve patient safety as well as

maintaining the hospital integrity. As a leader, utilizing my head, hand, heart and habits domains

will allow me to inspire change and invoke new practices within the unit. Patient safety would be

maintained through hygiene practice and interdisciplinary communication. Utilizing,

maintaining, and further refining these methods will assist in elimination of CLASBIs.

Looking at Memorial Regional’s Medical Telemetry unit, the goal of all staff is to

maintain hospital integrity. This means ensuring that the hospital environment is clean, safe and

healthy for patients to heal. Utilizing cross checks, such as asking if patients have been washed

with CHG and documenting their bath in their chart, will help maintain positive data and positive

health outcomes.

Outcomes Evaluation

My initial evaluation was prompted by central line hygiene. I would monitor CHG

bathing documentation, attend a quality improvement meeting at MRMC on behalf of my unit,

medical telemetry, and inquire to my team regarding how central line care can be successful.

MRMC’s Medical Telemetry recently received an award for maintaining a CLASBI free unit

from the infection control department. This is an incredibly high honor to receive from the

hospital system. Patient hygiene was properly documented 100% and the interdisciplinary team,

technicians to doctors, were properly informed of goals and how to achieve them, verbalizing an

understanding. 100% CLASBI free, all by utilizing different leadership domains.



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Haddadin, Y. (2018, September 30). Central Line Associated Blood Stream Infections

(CLABSI). Retrieved November 5, 2018, from

McAlearny, A. S., S.c.D MS. (2015, May). Final Report High-Performance Work Practices in

CLABSI Prevention Interventions: Executive Summary. Retrieved November 5, 2018,