Michael Dowling, CEO and President, North Shore-LIJ Health System
Bernard M. Rosof, MD, MACP, Senior VP, Corporate Relations and Health Affairs, North Shore-LIJ Health System, Chairman
Donna Armellino, RN, MPA, Infectious Disease, NSUH
Jens Bakke, MD, Infection Control, Syosset Hospital
Gary Blank, MBA, DPM, Director Clinical Program Initiatives, North Shore-LIJ Health System
Charles Cal, MBA, MS, RN, Assistant Director, Quality Management, North Shore-LIJ Health System
Jon Cohen, MD, Chief Medical Officer, North Shore-LIJ Health System
Yosef Dlugacz, PhD, Senior VP, Quality Management, North Shore-LIJ Health System
Dennis Dowling, Executive Director, NSUH and LIJ Medical Center
Barbara Edwards, MD, Infectious Disease, LIJ Medical Center
Bruce Farber, MD, Chief, Infectious Disease, NSUH
MaryJo LaPosta, RN, PhD, Deputy Executive Director and Chief Nurse Executive, NSUH
Alan Mensch, MD, Medical Director/Vice President of Medical Affairs/Chief, Division of Pulmonology, Plainview Hospital
Judith Moran, DNS, Assistant Director, Critical Care Nursing, Huntington Hospital
Alan Multz, MD, Director, Medical ICU, LIJ Medical Center
Michael Oppenheim, MD, Vice President, Chief Medical Information Officer, North Shore-LIJ Health System
Melissa Perez, MPA, Administrative Manager, Department of Medicine, NSUH and LIJ Medical Center
Brian Pinard, MD, Associate Chair of Surgery, NSUH
Anne Sacks-Berg, MD, Infection Control, Huntington Hospital
Carol Singer, MD, Chief, Infectious Disease, LIJ Medical Center
Lawrence Smith, MD, Chief Academic Officer, North Shore-LIJ Health System
Lily Thomas, PhD, RN, Vice President, System Nursing Research, North Shore-LIJ Health System
Peter Walker, MD, Chairman, Anesthesiology, Vice President for Anesthesia Services, North Shore-LIJ Health System
Maureen White, RN, MBA, CNAA, Senior VP, Chief Nurse Executive, North Shore-LIJ Health System

To increase quality of care and decrease hospital-acquired infections by standardizing best practice approaches used throughout the health system (a target percentage is being discussed, but has not yet been determined).

• Mortality data (as discussed with IHI regarding 100,000 Lives Campaign - collection for analysis is in progress)
• Infection rates (Surgical Site Infections
  Central Line-Related Infections, and Ventilator-Associated Pneumonia)

This improvement project is ongoing and is currently in its initial phases (August 2005) and already significant progress has been made in changing the health system’s culture to enhance patient care and reduce and prevent nosocomial infections.

• Established a multidisciplinary, system-wide committee to ensure that there is “zero tolerance for hospital-acquired infections.”
• A “white paper” was completed outlining the process, requirements, and resources necessary to achieve a “zero tolerance” culture for nosocomial infections.
• Identified project champion, process owner, and engaged all stakeholders.
• Collected and reviewed internal infection control data.
• Observed current internal practices via ethnographic study.
• Discussed observations with infection control practitioners, physicians, nurses, quality management, senior leadership, etc.
• Conducted research and interviews with external institutions.
• Initial assessment indicated need for infection control best practices to be standardized across the health system.
• 11 NS-LIJ Health System hospitals signed on to IHI 100,000 Lives Campaign in addition to signing on the the GNYHA/UHF CLABs Initiative as commitment to system-wide philosophy of zero tolerance for hospital-acquired infections. Hospitals included in the campaign are:  Forest Hills, Franklin, Glen Cove, Huntington, Long Island Jewish Medical Center, North Shore University Hospital-Manhasset, Plainview, Schneider Children's, Southside, Staten Island, and Syosset.
• Teams composed for implementation of each intervention.
• Education and training to be implemented as awareness heightens around infection control and the health system’s commitment to zero tolerance.
• Committee set forth additional system-wide infection control recommendations (consensus building).
• Process and outcome measures will continue to be collected for each intervention and system-wide recommendations.
• Data will be submitted quarterly (i.e., actual changes in the number and percentage of inpatient deaths).
• Reminders/prompts to comply with interventions.
• Findings will be shared internally and inform next steps.
• Provider and patient education and training will be ongoing.
• Standardized use of “best practices” across the health system.
  

We are in the initial phases of this improvement initiative and have already received tremendous feedback and commitment to zero tolerance for nosocomial infections throughout the health system.  Significant changes in our culture — communication, accountability, etc. — continue to be made that will decrease infection rates.  The support of senior leadership and both clinical (physicians, nurses, infection control practitioners, respiratory therapists, etc.) and non-clinical (environmental, housekeeping, etc.) staff has been instrumental in moving this initiative forward.

• Obtain commitment from the highest levels of the organization.
• Establish system and unit-level accountability in addition to a communication strategy.
• Build consensus.  (This may seem to be a laborious and time consuming process initially, but saves time long-term.)
• Provide education and training to facilitate behavior modification and overall culture change.
• Engage all parties in the change process to positively affect patient care.
  

Bernard Rosof, MD, MACP, Senior Vice President, Corporate Relations and Health Affairs
North Shore-LIJ Health System
brosof@nshs.edu