Background: Elimination of hospital-acquired infections is an important patient safety goal. Setting: All 174 medical, cardiac, surgical and mixed Veterans Administration (VA) intensive care units (ICUs). Intervention: A centralised infrastructure (Inpatient Evaluation Center (IPEC)) supported the practice bundle implementation (handwashing, maximal barriers, chlorhexidinegluconate site disinfection, avoidance of femoral catheterisation and timely removal) to reduce central line-associated bloodstream infections (CLABSI). Support included recruiting leadership, benchmarked feedback, learning tools and selective mentoring. Data collection: Sites recorded the number of CLABSI, line days and audit results of bundle compliance on a secure website. Analysis: CLABSI rates between years were compared with incidence rate ratios (IRRs) from a Poisson regression and with National Healthcare Safety Network referent rates (standardised infection ratio (SIR)). Pearson's correlation coefficient compared bundle adherence with CLABSI rates. Semi-structured interviews with teams struggling to reduce CLABSI identified common themes. Conclusion: Capitalising on a large healthcare system, VA IPEC used strategies applicable to non-federal healthcare systems and communities. Such tactics included measurement through information technology, leadership, learning tools and mentoring.

Background: Veterans Health Administration (VA) intensive care units (ICUs) develop an infrastructure for quality improvement using information technology and recruiting leadership. Methods: Setting Participation by the 183 ICUs in the quality improvement program is required. Infrastructure includes measurement (electronic data extraction, analysis), quarterly web-based reporting and implementation support of evidence-based practices. Leaders prioritise measures based on quality improvement objectives. The electronic extraction is validated manually against the medical record, selecting hospitals whose data elements and measures fall at the extremes (10th, 90th percentile). Results are depicted in graphic, narrative and tabular reports benchmarked by type and complexity of ICU. Results: The VA admits 103 68961156 ICU patients/ year. Variation in electronic business practices, data location and normal range of some laboratory tests affects data quality. A data management website captures data elements important to ICU performance and not available electronically. A dashboard manages the data overload (quarterly reports ranged 106d299 pages). More than 85% of ICU directors and nurse managers review their reports. Leadership interest is sustained by including ICU targets in executive performance contracts, identification of local improvement opportunities with analytic software, and focused reviews. Conclusion: Lessons relevant to non-VA institutions include the: (1) need for ongoing data validation, (2) essential involvement of leadership at multiple levels, (3) supplementation of electronic data when key elements are absent, (4) utility of a good but not perfect electronic indicator to move practice while improving data elements and (5) value of a dashboard.

Patient safety checklists are ubiquitous in health care. Nurses bear significant responsibility for ensuring checklist adherence. To report nonadherence to a checklist and stop an unsafe procedure, a workplace climate of psychological safety is needed. Thus, an analysis of organizational data was conducted to examine the relationship between psychological safety and reports of nonadherence to the central line bundle checklist. Results showed varied perceptions of psychological safety but no relationship with nonadherence. Considerations for this finding and assessing psychological safety are provided.