In many parts of Latin America, the quality improvement and patient safety movement is just getting started. A hierarchical health care system has made it difficult to promote quality and teamwork. But one project, known as Adios Bacteriemias, has made remarkable progress: 111 intensive care units (ICUs) in 40 participating hospitals in seven countries have reduced central line-associated bloodstream infections (CLABSIs) by 43 percent, improving patient safety in ICUs across Latin America. Even more remarkable is that the project — coordinated by IHI and the Latin American Consortium of Innovation, Quality, and Patient Safety (CLICSS) — is entirely virtual.
Santiago Nariño, former project assistant for the IHI Latin America team, spoke with Jafet Arrieta, MD, MMSc, (pictured above) a Mexican physician who helped lead the project as IHI Improvement Advisor and Faculty.
Q: How did you become interested in quality improvement?
I have seen the importance of quality improvement at various points in my career. In my fifth year at the Tec de Monterrey Medical School, I had the opportunity to do rotations in public and private hospitals. One of the things that really struck me is the gap in the quality of care patients receive, care being remarkably better in private hospitals. Through my experience working in Chiapas, one of the poorest and most underserved states in Mexico, I became aware of how economically- and socially-disadvantaged groups face not a gap, but a chasm in health care quality. This chasm is especially evident in their lack of access to health services, the low quality of the services available, and the inequitable health outcomes.
Q: What have you learned over the last five years through your work in quality improvement in Latin America?
I strongly believe health is a human right. I believe that approaching health as a basic right must be accompanied by the aims of quality and equity and not just access to health care. In Mexico and Latin America, there has been a huge push to improve access in the recent years, but less attention has been paid to quality of care and patient safety. It is a common belief that access equals quality, but that really is not the case. Quality is part of the ultimate goal of health systems, and as such, it should go hand in hand with access. Both access and quality should be seen as a means to an end — the goal of improving health and health care for the patients we serve.
From my experience in Latin America and, more specifically, from my experience working on the Adios Bacteriemias campaign, I have become aware of the sociocultural barriers to quality improvement in Latin America, including lack of awareness of quality and patient safety issues, resistance to change, vertical hierarchies, and the lack of quality-oriented systems. The more we start to analyze the results of our work in the Adios Bacteriemias campaign, the more we see how important it is to take the local context into consideration and adapt, rather than just adopt, evidence-based interventions and improvement initiatives to the Latin American setting.
Q: What else have you learned about quality improvement in Latin America? What made Adios Bacteriemias so successful?
I have learned that creating awareness, building will, involving all stakeholders, assembling strong local teams, and communicating the vision from the beginning are fundamental to setting the stage before starting the improvement efforts.
After two phases of the campaign, we believe the key factors that made Adios Bacteriemias successful include the convergence of expert organizations and QI subject matter-experts, the adaptation of the interventions to the local context, the development of networks within each country, and the sense of connectedness and belonging to a community aiming to improve patient safety in the region.
Q: What do you think the rest of the world can learn from this effort?
It’s been such an amazing journey. The magnitude and impact of the campaign has brought drastic results at all levels. I think this campaign could be a new model for IHI and others to use in contexts where there are scarce financial resources. There are several reasons for this:
Despite the fact that the campaign had almost no financial backing and was entirely virtual, participants were actively engaged and achieved significant results.
The hard work of individuals and organizations drove this campaign to success. However, the fact that the members of the campaign task force are volunteers may make this model unsustainable from an implementation perspective in the long run.
Adios Bacteriemias has demonstrated that it is possible to create a multi-country movement towards quality improvement and patient safety in Latin America, which has the potential for being replicated in similar developing regions.
Despite the heterogeneity in size and type (e.g. public vs. private, academic vs. non-academic) of the participating hospitals, a spirit of collaboration amongst the teams created an environment of “all teach, all learn,” that allowed us to succeed.
The natural dissemination of information through countries and cities was probably the most impressive asset of the campaign. For example, when we started the project, we were concerned that we were not going to get enough hospitals for the demonstration phase. However, over 150 hospitals registered from Argentina, Chile, Colombia, Mexico, Peru, Uruguay, and Venezuela.
Q: What is next for Adios Bacteriemias?
The second phase of the campaign is currently six months into its sustainability period. We consider sustaining the changes to be the next challenge for the participating hospitals that achieved a significant reduction in the rate of CLABSI. Therefore, as part of this phase we continue to provide coaching and online support during the sustaibility period, and the participating hospitals continue to report their process and outcomes.
Based on the experience with the Adios Bacteriemias campaign, and with the intention of demonstrating that it is possible to translate the learnings of the campaign into other quality improvement initiatives, we launched a new campaign, Adios Neumonias, aimed at reducing ventilator-associated pneumonia. Fifty-two ICUs from 19 hospitals in four Latin American countries (Argentina, Colombia, Mexico, and Uruguay) have registered for the campaign so far.
For more information, visit www.clicss.org or send an email to firstname.lastname@example.org
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How-to Guide: Prevent Central Line-Associated Bloodstream Infection
How-to Guide: Prevent Ventilator-Associated Pneumonia
Patient Safety Executive Development Program, March 3-9, Cambridge, MA