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Leadership Strategy Analysis

Leora Bain. Jean-Baptiste Kagabo, Katelyn Gaffney, & Amanda Serio
Ferris State University

When applied to healthcare environments, quality improvement (QI) is an important
process used in ensuring the safety and quality care of patients. Steps involved in quality
improvement include identifying a need to be addressed, assembling an interdisciplinary team,
collecting data on the current status, establishing measurable outcomes and quality indicators,
selecting and implementing a plan, and collecting data to evaluate results. These six steps of QI
are used to address high incidence rates of catheter-associated urinary tract infections (CAUTI)
in healthcare setting. The desired end-results of quality improvement, is an improved healthcare
environment that leads to better outcomes for patients.


Leadership Strategy Analysis

The purpose of this paper is to analyze the quality and safety initiatives associated with
the high incidence rates of CAUTI, as well as to advocate for healthcare improvement. The
leadership strategy utilized will be the ADKAR model of change in conjunction with Kotters 8
step model. The ADKAR model breaks down the change process into five levels, awareness,
desire, knowledge, ability, and reinforcement which will be discussed in more detail (Varkey &
Antonio, 2010). It will be shown here how using this model in conjunction with Kotters 8 step
model; will provide the tools necessary for a successful change.
A urinary tract infection (UTI) is an infection occurring in the upper or lower urinary
tract, (Smeltzer, Bare, Hinkle, & Cheever, 2010, p. 1359). The Centers for Disease Control
(CDC) (2015) estimates approximately 13,000 deaths annually, related to UTIs (p. 1). The most
significant risk factor for developing CAUTI is the prolonged use of urinary catheters (Centers
for Disease Control [CDC], 2015). It is for this reason that urinary catheters should only be used
when appropriate and removed as soon as possible (CDC, 2015).
Clinical need
Thirty-four percent of all healthcare-associated infections (HAI) are related to the use of
urinary catheterization (Fink et al., 2012, p. 1). Equaling more than 500,000 CAUTIs annually,
CAUTIs are a major source of excess resource utilization (Fink et al., 2012, p. 1). The American
Academy of Nursing (AAN, 2014) states, CAUTIs are responsible for an annual increase of
$131 million in U.S. healthcare costs, (p. 1). Common complications related to CAUTIs include
endocarditis, prostatitis, epididymitis and orchitis in males, and cystitis, pyelonephritis, gram-


negative bacteremia, vertebral osteomyelitis, septic arthritis, urosepsis, endophthalmitis, and

meningitis all of which significantly increase the patients length of stay and costs of care (CDC,
2015, p. 1).
Interdisciplinary team
Depending upon the type of complications experienced by individual patients as well as
their initial reason for admission, the interdisciplinary team will consist of a broad array of
professions. This may include; physicians, nurses, aides, multiple therapy departments, risk,
quality and care management, as well as supervisory staff. In creating a quality and safety team
for CAUTIs, there should be one or more representatives from each of these areas (Varkey &
Antonio, 2010, p. 269). Before starting the QI process, members of the interdisciplinary team
may need to be educated about their roles in order to maximize success (Yoder-Wise, 2015).
Physicians are included in the interdisciplinary team because they make the decision to
order catheter placement, and diagnose complications related to catheters. Nurses make
recommendations for catheter orders, insert catheters, assess patients with catheters, and remove
catheters. Nurse aides, wash and clean patient, empty urinary bags, and help patients get in and
out of beds. While performing these tasks, bacteria can find their way into the urinary tract (UT),
therefore nurse aides should be included on the team. The urinary catheter can accidentally be
contaminated when moved back and forth in the urethra and introduce bacteria into the UT when
physical therapists (PT) or occupational therapists (OT) are working with patients, for this reason
their inclusion on the team is justified. Quality management and risk management go hand in
hand, they both focus on optimizing patient outcomes and emphasizing prevention of patient care
problems and lessening of their adverse effects (Yoder-Wise, 2015). For this reason, members


from supervisory staff, risk management, and quality management are included in the
interdisciplinary team.
Data collection method
Data will be obtained from the hospitals laboratory database, and by collecting risk
management data regarding the incidence of CAUTI infections per nursing unit. To determine
the incidence of CAUTIs, the team will analyze the number of urinary catheter days and compare
them to the number of patient days. The team will then cross reference this data to the incidence
of CAUTI infections per 1000 patient days. A chart review form will be created and utilized for
all organism positive urinalysis (UA) data (see Appendix). Once all data has been collected via
the laboratory data base for the last fiscal quarter, patient charts will be reviewed to determine
whether they fit the inclusion criteria.
The criteria for inclusion in this study will be: positive UA following hospital admission
with concurrent use of urinary indwelling catheter, as well as recent discontinuance of an
indwelling urinary catheter with and without a diagnosis of secondary bloodstream infection.
Data related to uncompensated hospital costs occurred as a result of these infections will also be
obtained and analyzed.
A measure of relationship between the use of urinary indwelling catheters and CAUTI
data sets will be analyzed using the Spearman Rho correlational procedure. Information
regarding secondary bloodstream infections as well as other complications due to the CAUTI
will also be gathered and analyzed using the Spearman Rho correlational procedure. Information
related to the costs of CAUTI and associated illnesses will be analyzed using measures of central


The next step will be to analyze the guidelines and protocols utilized for urinary catheter
insertion as well as removal of unnecessary catheters to determine any changes that need to be
made based on current evidence-based practice research. An overview of the costs of such
infections will then be generated for the last fiscal quarter and put into an understandable format
for review by the unit managers through the use of frequency distribution per unit and measures
of variability between the units.
Due to the high incidence rates of CAUTI, there have been many methods designed to
prevent this HAI from occurring. One method was tool was created by the American Nurses
Association (ANA). The ANA guideline tool, first lists specific criteria for indwelling catheter
placement. If a patient meets the requirements for placement, an indwelling catheter is placed,
and additional guidelines are implemented to care for the patient and catheter to prevent a
CAUTI from occurring (Nursing World, 2015). The outcomes for a patient with an indwelling
catheter need to be focused around prevention.
Cleansing of the catheter area will occur twice in a 24 hour period. Maintaining a clean
area around the catheter tubing and the genital area will decrease the occurrence of bacteria
entering the urethra and causing a CAUTI. In order to ensure this, staff will cleanse the catheter
tubing and genital area properly with soap and water twice a day, or additionally as needed.
Staff will evaluate the patients need for an indwelling catheter every 24 hours.
Discontinuance of the catheter will occur as soon as medically possible. Documentation
compliance will be 100 percent by the end of the quarter to ensure appropriateness of
catheterization as well as maintenance of the urinary catheter. Educational requirements will


reach 100 percent completion by the end of the quarter. Finally, the rates of CAUTI will be
reduced by 40 percent by the end of the next fiscal year.
Strategies for implementation
Using the ADKAR method, the first step to implementing change in this area, is to
provide awareness to the need for change (Varkey & Antonio, 2010, p. 269). Kotters 8 step
model in conjunction with ADKAR breaks the first step of creating awareness into 4 more
detailed steps (Varkey & Antonio, 2010). Therefore, in creating awareness of the needed change,
the team will first increase the urgency for change, then build a team for implementation which
will work together to construct the vision, then communicate the change to the facility (Varkey
& Antonio, 2010, p. 269).
In the particular case of creating awareness of the needed change among the facility, it
would be ideal to start by providing statistical information regarding the facilitys incidence rates
of CAUTI, the increased cost for the facility, and the morbidity and mortality rates for the
consumers at the facility. Another measure that would increase the awareness of need for the
change as well as the sense of urgency would be to relay to the staff the facilitys budget and
what it would mean for the staff if the incidence rates continued (i.e. hiring freezes, layoffs, etc.).
This would relay to the staff the significance of how this problem can affect them personally.
After increasing the desire to make the change, ADKAR requires increasing
knowledge on how to change, and the ability to implement new skills and behaviors,
(Varkey & Antonio, 2010, p. 269). These three steps encompass the next phase of Kotters 8 step
model, to empower the staff in making the needed change (Varkey & Antonio, 2010, p. 269).


Kotters 8 step model adds two additional steps to this phase in which management will create
short term goals, and be persistent in making the necessary changes (Varkey & Antonio,
2010, p. 269).
To empower staff to make the needed change, educational seminars and continuing
education units will be created, on appropriate use of urinary catheters, hand hygiene, and
catheter care. To build on this education, managers can supervise staff while performing catheterrelated tasks during performance evaluations to determine competency. These educational
opportunities will serve to educate staff on the appropriate use of catheters as well as determining
situations where bladder training programs should be implemented as well as the use of
intermittent straight catheterization in an effort to reduce the occurrence of CAUTI. This
education, implementation, and evaluation procedure will also fulfill the criteria for creating
short-term goals and being persistent in making the change.
In the final phase for implementing change according to ADKAR, the team must provide
reinforcement to retain the change once it had been made, which runs concurrently with
Kotters last step, making the change permanent, (Varkey & Antonio, 2010, p. 269). In this
case, making the change permanent will include continued use of the Urinary Catheter
Questionnaire, (see Appendix A) to gather statistics and data related to catheter care and
incidence of infection. Providing updates to staff as well as updates related to the budget
improvements will help them to see how the change has positively affected their patients,
employer, and themselves. This will provide the continuation of the change by increasing the
staff willingness to participate and train new staff appropriately.


Clinical staff learning related to proper use and indications for Foley insertion will be
tested following the learning modules. In addition, there will be continued monitoring of the
occurrence of CAUTI and associated complications by means of the online form required for all
catheter insertions as seen in Appendix A. This form will serve to collect any relevant data
related to the appropriateness of catheterization, catheter days, secondary complications, and
other relevant data to the study. The Independent-T test will be utilized to determine
effectiveness of the interventions listed in decrease the incidence of CAUTI and its associated
The Centers for Disease Control (CDC) (2015) estimates approximately 13,000 deaths
annually, related to UTIs (p. 1). Academy of Nursing (AAN, 2014) states, CAUTIs are
responsible for an annual increase of $131 million in U.S. healthcare costs, (p. 1). By creating
QI teams consisting of members from a variety of health-care related fields, valuable information
and techniques can be implemented for improving patient outcomes and reducing the occurrence
of CAUTI within the hospital setting using the ADKAR model of change in conjunction with
Kotters 8 step model. After collecting and analyzing the data, evidenced-based interventions and
educational requirements will be implemented. The main goal of the QI process is to improve
documentation, reduce unnecessary use of indwelling urinary catheters, and reduce the instance
of CAUTI and secondary complications by at least 40 percent by the end of the next fiscal year.
This will serve to improve patient outcomes and satisfaction, and reduce the amount of
unreimbursed hospital expenditures related to HAIs.


American Academy of Nursing. (2014). American academy of nursing, choosing wisely: Urinary
catheters. Retrieved from
Centers for Disease Control. (2015). Catheter-associated urinary tract infections (CAUTI).
Retrieved from
Centers for Disease Control. (2015). Urinary tract infection (catheter-associated urinary tract
infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) and other
urinary system infection (USI) events. Retrieved from
Fink, R., Gilmartin, H., Richard, A., Capezuti, E., Boltz, M., & Wald, H. (2012). Indwelling
urinary catheter management and catheter-associated urinary tract infection prevention
practices in Nurses improving care for healthsystem elders hospitals. American Journal
of Infection Control, 1-6.
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarths
textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Wolters Kluwer
Health/Lippincott Williams & Wilkins.



Varkey, P., & Antonio, K. (2010). Change management for effective quality improvement: A
primer. American Journal of Medical Quality, 25, 268-273.
Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.). St. Louise, MO: Elsevier.


Appendix A
Original Date:
Dates Revised:

Urinary catheter QUESTIONNAIRE


(Last, First, M.I.):

Date of insertion:


Date of discontinuance:

Catheter associated infections

Secondary Complications:
Other Secondary:


Septic arthritis endopthalmitis









List any medical problems that have been diagnosed

Catheter Days

Prescribed drugs
Name the Drug

Allergies to medications
Name the Drug





Frequency Taken



Does this patient have a catheter inserted?



Was there an order placed?



Is this a reinsertion?



Has the catheter requirements been reviewed for appropriateness?



Are there other interventions that could be used instead?



Criteria for inserting/maintaining a Foley Catheter

Strict I&O-Critically ill

Acute retention/obstruction
Epidural catheter
Paralysis/ Deep sedation
Significant skin breakdown
Spine precautions

Crush injury or pelvic fx

Comfort, end of life care
24hr collection
Acute head injury
Surgery: Urologic
Surgery: Colorectal

Surgery: C-section
Surgery: Abdominal
Surgery: Pelvic
Surgery: Cardiac
Surgery: Other prolonged