 Hi everybody. This is Donna Frost, our Chief Clinical Officer at the Patient Safety Movement Foundation. We're here to bring you another patient safety update today, and we're excited to have an interview today with Dr. Bob Heisey, Medical Director of the Critical Care Medical Unit and Professor of Medicine at the University of Michigan Health Care System. And today we're going to be talking with Dr. Heisey about is reducing the incidence of central line associated bloodstream infections, otherwise known as CLABSI. Welcome, Bob. Thanks for joining us today. Thank you for having me, Donna. Can you tell us a little bit about your background and how you got involved in the CLABSI work that you do? Well, as a medical director of ICU, I'm responsible for the delivery of medical care on the physician's side, and I was also involved at a state level here in Michigan with our hospital association, the Michigan Health and Hospital Association. Some years ago, one and 15 years ago, and we were creating a toolkit for ICU quality improvement, and toolkits kind of sit on a shelf in a book, and they don't really get to the bedside. But while I was in Lansing for the meeting, the vice president of the Michigan Health and Hospital Association Keystone Center for Patient Safety Quality, a woman named Chris Schoeschel, inquired our group, if we'd like to participate in this thing called a collaborative, and a physician named Peter Proto-Host, who was at Johns Hopkins, was going to interact with us in Michigan regarding a checklist for CLABSI insertion and maintenance that he had examined at Johns Hopkins. So on a small scale, a single center kind of thing, and the idea was, could we roll this out to a larger entity, and Michigan seemed like a fertile ground for that. And I was excited about it, and I remember coming back to my hospital leadership study, and we really want to do this thing and talking to my ICU leadership, saying we're in, we're going to do this. And so it was a groundbreaking effort led by Peter, as I said, and Chris. And it was groundbreaking in a number of ways. First of all, it was an implementation of the checklist, which became popular to go on, they published a book called The Checklist Manifesto about a surgical checklist, but this was a line insertion checklist. So it was groundbreaking that way. It was groundbreaking in this notion of a collaborative, a bunch of hospitals getting together, all trying to learn from each other, support one another, and achieve results, and CLABSI being one of the major targets. And it was groundbreaking in third way, which was results. And we had a paper published by God 14 years ago now in the Journal of Medicine, which was a statewide analysis of the pre versus post implementation of the central like checklist, where we reduced the median CLABSI rate in the state to zero. So it was groundbreaking that regard also for achieving results and for achieving like a zero defect kind of phenomenon. So it really changed the paradigm, if you will, for CLABSI with an ocean of zero defects being achievable. And, you know, I think to that point of a lot of people, we'd always say my patients are different, you know, just the rules don't apply to me, right? But I think that because of that work, collaborative study done nationwide, a lot of emphasis on CLABSI as a achievable entity, the government picked up on this notion. I think they went too far and tried to extrapolate it to other entities where zero defects are not quite achievable. Delirium, for example, I'm not sure how to keep every last patient become delirious. CLABSI as an entity where you could improve things. And what happened over time, frankly, is that people paid attention. And CLABSI rates nationwide really plummeted. So when you look at the benchmark and actual benchmarking, I mean, even if you improve your rates significantly, the rest of the country improved as well. And so your percentile compared to comparators might still be mediocre, even though compared to your historic results, you're doing phenomenally well. So that was a big entity. And we kept the collaborator going for many years and took on many other things, the ABC to EF bundle, which later became the ICU liberation bundle, a bunch of CLABSI, a bunch of other things. But we always held CLABSI near and dear our hearts because that was the master stroke, if you will. That was the thing that put Michigan's Keystone Center on the map. That's the thing that really put collaboratives on the map. That's the thing that changed paradigm with compared to zero defects. Wow, that's great work. And, you know, those of us in the quality and safety space have been following that work for years. As you mentioned, it's been, you know, quite some time that we've been advocating for CLABSI bundles and the checklist, the use of the checklist. So my question to you, we've done a lot of great work. We have reduced errors significantly and infections significantly in patients with central lines, but we're not at zero. So can you tell us a little bit about why you think that is? Well, you know, a hospital like a 7-11 never closes, and yet people come and go and you have to continue to keep your eye on the ball and continue to do this work. It never goes away. So, you know, people come and are trained and have to embrace the culture. And so, you know, I think part of the problems are that, you know, collaboratives kind of were trendy and now they're not trendy anymore, you know, or and people were required to implement lots of things, lots of bundles and checklists. I think that ultimately, and I know Peter would agree with this quite a bit, Wesley Lee down at that event, you know, it's a culturally strategy for lunch. So a lot of places now have to do these things, and as you pay lip service to them, you know, we've got a checklist. Of course we do. We've got a bundle. We've got this. We've got that. They know they have to do that, but unless you have the culture that animates them, you're never going to succeed long term and the culture has to be sustained because there's turnover. People move on and you have to maintain that culture. So I think a lot of places have these things on paper now. And that was the beauty of these collaboratives, you know, over the day. We've got some toolkits that are meaningless, really, operationalize things at that site to cultural change. Part of the thing about Keystone that sometimes people have forgotten was that cultural change was also really probably the most important thing that happened. There was a guy named Jay Bryant from Sexton who studied the cultural thing. And I remember a little bit quarterly article, you know, kind of Understanding Michigan or something was called. In other words, what the heck happened that really made this collaborative work? It's not so easy, right? Cultural change and sustainability of cultural change is not that easy. Again, if you have people from the top down, say, oh, you must do this, I don't doubt that people will superficially comply. But, you know, the thing about Keystone also was it was bottom up, right? It was a cultural change that made the results rather than someone saying, oh, you better have a checklist, you know, your hospital administrators and say, oh, we've been on a checklist. And that doesn't really get the job done. So it's all about it. Ultimately, it's all about culture. Absolutely. And that's something that we talk about a lot here at the Patient Safety Movement Foundation. You know, we'll never be successful in improving those population-specific medical errors if we don't first address that foundation of safety and reliability. So give us some some insight into what hospitals can do to to maintain that culture of safety. Well, you know, I think there's there's leadership, which is important and leading by example, which is important and there's empowerment, which is currently important as well. In other words, I mean, Peter used to have a great anecdote. He was great in front of a live crowd. His anecdote that he would say was, would your most recently hired nurse feel comfortable telling their, your most experienced doctor who's putting in a subtle line approach to their diagnosis, stop time out, you blew it, you got to start over again. And then the audience would, of course, uniformly laugh, kind of a nervous laugh, and he would say, what are you laughing about? Right? And then and then you kind of have that reality check here. Well, yeah, what am I laughing about? Because after all, it's an unsafe event. But I think it's an instructive anecdote, right? Because empowerment is part of it, part of it as well. And without that, you will not have the cultural issues that you want. You don't have the culture you need to succeed. So people have to feel invested. They have to feel seen and heard. They have to feel they're part of something important. If it's just mandated from on high and they really checking a box that they've got, they've got a bundle. And they're superficially complying just to get the man off their case, you know, whatever it is, nothing's going to happen. So the positive cultural thing is you have to have possible leadership support. We did a piece of very important to have hop down hospital leadership, engage to empower the local people, right? So that's what it has to be a little bit of letting go to trust your rank and file as well to do that. I think that's true. I think everywhere, right? If you're building Arizona assembly line, I mean, quality circles or whatever, the totally quality management issue. So people have to have skin in the game, I guess, and they have the cultural change. But leadership, you need the leadership of both to support the people below that they show that they're valued rather than they're just kind of, I don't know, just that worthwhile or something like that. I mean, a lot of things, I'll have to get a hospital going, you know, in the recent COVID pandemic, you know, I pointed out to some of my colleagues, I said, you know, the people cleaning these beds are critically important. I mean, they are, you know, I mean, people look right through them like they don't exist. But you know, try having a hospital function unless if 20% of those guys are sick or they call in or whatever, you know, I mean, so it's a team effort at a lot of levels. I mean, I just use that as an example, of course, nursing, pharmacists, respiratory therapists, all these people doing their tasks make it work. And they're all critically important. And you can't, you can't just assume the doctor's going to walk in and then, you know, pontificate and expect something, something good to come with that without engagement and empowerment. Wow, that is so very well said. Thank you so much for joining us today. I know that our network is going to be really happy to hear this information. And, you know, and I think it's, it's, it's something that we've learned over the last 20 years, I think that that we have to really focus on this foundation. And it's probably going to take us another 10 to 20 years to get there. But folks like you are leading the pack. So thank you so much for everything that you're doing. My pleasure. Well, have a wonderful day and we hope to have you back again. Okay, thanks a lot.