706542

research-article2017
AJMXXX10.1177/1062860617706542American Journal of Medical QualityOrwoll et al

Article
American Journal of Medical Quality

Gamification and Microlearning for

1­–9
© The Author(s) 2017
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DOI: 10.1177/1062860617706542
https://doi.org/10.1177/1062860617706542

(GAMEQI): A Bundled Digital ajmq.sagepub.com

Intervention for the Prevention of

Central Line–Associated
Bloodstream Infection

Benjamin Orwoll, MD1,2, Shelley Diane, RN, MSN, CCNS3,

Duncan Henry, MD1, Lisa Tsang, RN, MN, CPHON3, Kristin Chu, MBA1,
Carrie Meer, RN, MS, CPHQ4, Kevin Hartman, MS1, and
Arup Roy-Burman, MD1

Abstract
Central line–associated bloodstream infections (CLABSIs) cause major patient harm, preventable through attention
to line care best practice standards. The objective was to determine if a digital self-assessment application (CLABSI
App), bundling line care best practices with social gamification and in-context microlearning, could engage nurses
in CLABSI prevention. Nurses caring for children with indwelling central venous catheters in 3 high-risk units were
eligible to participate. All other units served as controls. The intervention was a 12-month nonrandomized quality
improvement study of CLABSI App implementation with interunit competitions. Compared to the preceding year,
the intervention group (9886 line days) CLABSI rate decreased by 48% (P = .03). Controls (7879 line days) did not
change significantly. In all, 105 unique intervention group nurses completed 673 self-assessments. Competitions were
associated with increased engagement as measured by self-assessments and unique participants. This model could be
extended to other health care–associated infections, and more broadly to process improvement within and across
health care systems.

Keywords
game theory, engagement, quality improvement, health care–associated infections, education

US medical errors are estimated to cause 251 000 to 440
000 deaths per year.1,2 US health care expenditures are
approaching 20% of gross domestic product, with the
cost of waste estimated at $558 billion to $1.263 trillion
annually.3,4 The costs of failures of care delivery (eg,
patient safety best practices) alone exceed $100 billion.4
Health care systems have established best practices that
can improve outcomes and operational efficiency; the
challenge is engagement of frontline staff for consistent
implementation.5,6 Digital technologies including social
media, cloud computing, and mobile technology offer a
low-cost opportunity for the digital transformation of
process improvement.7
Health care–associated infection (HAI) represents a
major preventable harm and adds nearly $10 billion annu-
ally to US health care spending.8 Central line–associated
bloodstream infection (CLABSI) is associated with an
estimated mortality rate of 18% to 25% and prolonged
hospital stays.9-11 CLABSI can be reduced through dili-
gent application of standard best practice care bundles,12
though improvements in bundle compliance may not be
sufficient to decrease rates of infection.13 The Affordable
1
University of California San Francisco, CA
2
Oregon Health and Science University, Portland, OR
3
UCSF Benioff Children’s Hospital, San Francisco, CA
4
UCSF Medical Center, San Francisco, CA
Corresponding Author:
Benjamin Orwoll, MD, Department of Biomedical Informatics and
Clinical Epidemiology, Oregon Health and Science University, 3181
SW Sam Jackson Park Rd, BICC 5th Floor, Portland, OR 97239.
Email: orwollb@ohsu.edu
2 American Journal of Medical Quality 00(0)
Care Act of 2010, through the Centers for Medicare &
Medicaid Services (CMS), established the Hospital-
Acquired Condition (HAC) Reduction Program, provid-
ing hospitals a financial incentive to reduce HACs.14 The
first year (12-month period beginning October 1, 2014)
targeted 2 major HAIs: CLABSI and catheter-associated
urinary tract infections. A total of 721 hospitals, including
nearly half of all academic medical centers, were penal-
ized a total of $371 million for excessive rates of HACs.15
Safe and high-quality care is critically dependent on the
level of engagement of the clinical team.16 Engagement of
the end users of a system is nowhere more evident than in
the gaming industry, which generates more revenue than
film and engages every major demographic.17,18 Millennials
have entered the health care workforce. These “digital
natives” have grown up in an environment framed by social
media and technology, including gaming. “Gamification” is
the application of game mechanics in nongame contexts
and has been used extensively in consumer applications to
drive engagement and performance.19 “Social gamifica-
tion” is the application of these mechanics in social media
environments to amplify behaviors and increase engage-
ment, especially among growing technology-native demo-
graphics.20 This approach could be used to promote
microlearning—contextual technology-enhanced focused
learning—which, with the ubiquitous prevalence of smart
phones, is expected on demand for the support of common
consumer tasks outside of health care.21 Such learning
could potentially affect health care provider behavior and
patient outcomes, driving both compliance (what to do) and
fidelity (how to do it).
Objective
The use of formalized social gamification in HAC reduc-
tion efforts is heretofore unreported. Through a con-
trolled study of nurses caring for a high-risk population,
the study team sought to determine if a bundled interven-
tion consisting of social gamification integrated with in-
context microlearning and digitized institutional central
line care best practice could engage nurses in CLABSI
prevention.
Methods
Setting
The study population consisted of nurses at University of
California San Francisco (UCSF) Benioff Children’s
Hospital (study hospital), an academic quaternary care
institution. The study period extended from September
2014 through August 2015. Importantly, the study hospi-
tal moved to a new facility in February 2015. All staff and
units relocated simultaneously. Participation in the study
was voluntary. Nurses whose primary assignments were
to one of the intervention units were eligible to partici-
pate. Eligible nurses could complete self-assessments
during shifts in which they cared for a patient with an
indwelling central venous catheter (CVC). CVCs
included standard temporary, peripherally inserted,
hemodialysis, and long-term tunneled central catheters,
as well as implanted vascular access ports.
The UCSF institutional review board granted a waiver
of consent and approved publication of study results.
Application Development
The study team developed a CLABSI self-assessment
application (CLABSI App) for an existing cloud-based
enterprise social network platform (Chatter, Salesforce
Inc., San Francisco, California). Staff were familiar with
the platform through a previously developed peer-recogni-
tion application. The CLABSI App was specifically cre-
ated for workstation use, and access was facilitated by a
single sign-on system. The CLABSI App was designed as
a self-assessment checklist, mirroring the institutional
CLABSI prevention nursing care bundle audit tool (Table
1), and tracking CVC type and location, together with
associated nurse and unit. The CLABSI App did not
include protected health information (PHI) and was not
linked to the medical record. Intervention group nurses had
unrestricted access to the CLABSI App and were encour-
aged to complete self-assessments toward the end of their
clinical shifts. Data were stored securely on an enterprise
data cloud. A video example of the CLABSI App is avail-
able (https://vimeo.com/202998805/02ccb2a1d3).
The CLABSI App integrated just-in-time microlearn-
ing, including in-line explanations of each institutional
CLABSI prevention bundle element and pop-up on-
demand video demonstrations. Nurses could view their
own self-reported compliance by individual element, and
compare personal performance to the aggregate perfor-
mance of their respective units. The CLABSI App was
paired with a commercial gamification engine
(LevelEleven, Detroit, Michigan) designed for the social
network platform. This allowed the creation of custom-
ized teams and competitions across shifts and units.
The cost for development of the CLABSI App and
integration into the institutional social network platform
was approximately $60 000. This includes the subscrip-
tion cost for the gamification software-as-a-service.
Study Design
A prospective nonrandomized controlled study was
designed wherein the bundled intervention was a targeted
implementation of the CLABSI App at the unit level,
with competitions between nursing groups. There were
Orwoll et al 3
no other new hospital-wide CLABSI prevention pro-
grams initiated during the study period. Access to the
CLABSI App was limited to those nurses whose primary
unit was in the intervention group, as already described.
Intervention group units (bone marrow transplant, hema-
tology-oncology, general critical care) were selected
based on historically higher rates of CLABSI, attributed
to their disproportionately larger immunocompromised
patient populations. All other inpatient units comprised
the control group (neonatal intensive care, cardiac critical
care, cardiac transitional care, general medical/surgical
transitional care, general medical/surgical ward).
Beginning in the 10th month of the study, 2 control units
requested and received access to the App. Neither unit
had a subsequent CLABSI through the duration of the
study. Subsequent line days from those units were not
included in CLABSI outcome analysis.
Competitions lasted one month each, with shift- or
unit-based teams earning points for each self-assessment
completed. Competitions took place in September 2014,
June 2015, and July 2015, and were formally publicized
via staff meetings, posters, and email. Winning teams
were awarded a shared prize of nominal value (eg, food,
gift cards, raffle tickets). Nurses in enrolled units were
allowed to continue completing self-assessments through
the App in between competition months. A diagram dem-
onstrating the workflow for study participants is shown in
Figure 1.
Outcome Data
The primary outcome was CLABSI rate, as obtained
from study hospital institutional quality improvement
(QI). Each CLABSI incident was determined indepen-
dently by the study hospital Infection Control department
per National Healthcare Safety Network definition, which
was consistent between the historical and study periods.22
The CLABSI rate during the study period was compared
to the 12-month period immediately prior (preceding
year), with additional control analysis extending 24
months prior to the study period (baseline period).
Changes in CLABSI rates were compared between inter-
vention and control groups. Secondary outcomes included
numbers of self-assessments completed and the self-
reported compliance with each CLABSI bundle element
listed in Table 1. The study team compared self-assess-
ments with independent observer nursing audits con-
ducted during the study period and preceding year. Unit
nursing leadership (clinical nurse specialist, manager, or
designee) conducted independent observer audits as part
of an existing ongoing hospital-wide effort to measure
and promote CLABSI prevention bundle compliance.
Table 1.  Study Hospital CLABSI Prevention Best Practice
Bundle.a
Is a daily screen of need for central line documented on your
shift or the previous shift?
Is the central line system intact?
Is the central line dressing clean, dry, and intact?
Is a BioPatch present and correctly placed?
Is the dressing change date ≤7 days old for transparent
dressings OR ≤48 hours old for gauze dressing?
Is the central line tubing change date ≤96 hours old, OR ≤24
hours old for medications requiring more frequent tubing
change?
Was the patient bathed at least once during your shift or the
previous shift?
Did you ALWAYS perform hand hygiene prior to providing
central line care?
Were ALL IV medications or fluids administered with aseptic
technique?
Were ALL blood draws from central line for lab specimens
done with aseptic technique?
Were ALL central line tubing changes, if done on your shift,
done with aseptic technique?
Were ALL central line dressing changes, if performed on your
shift, done with aseptic technique?
Abbreviations: CLABSI, central line–associated bloodstream infection;
IV, intravenous.
a
The 12 CLABSI prevention bundle elements included in the self-
assessment app are listed. Core bundle elements also present in the
standard independent nursing audit checklist are underlined.
Statistical Analysis
CLABSI rates are represented as the total number of
CLABSIs per 1000 line days. Normally distributed vari-
ables are represented as mean ± standard deviation, and
nonnormally distributed variables as median ± inter-
quartile range (IQR). The study team compared CLABSI
rates during the intervention period with expected val-
ues based on the preceding year using the χ2 test. The
team analyzed the occurrence of CLABSI using a
Poisson regression model with a log link function, with
effects for unit group, study period, and unit group-
study period interaction (the latter measuring the effect
of the intervention), and with log-transformed line days
exposure as an offset variable. Rates of audits per line
day and compliance with individual bundle elements
were compared using the 2-sample test of proportions.
The number of self-assessments completed were com-
pared between contest and noncontest months using the
Wilcoxon rank-sum test. An alpha cutoff value for sig-
nificance of .05 was used. Analyses were conducted
using Stata 13.1 (StataCorp, College Station, Texas) and
R Version 3.1.1 (R Foundation for Statistical Computing,
Vienna, Austria).23
4 American Journal of Medical Quality 00(0)

Figure 1.  CLABSI App and gamification workflow.

Flow diagram detailing the steps involved for study participants to use the CLABSI App and participate in gamification competitions. Components
that exist within the social network are enclosed within the outline. See Supplementary Material for high-resolution version of Figure 1, available
with the article online at ajmq.sagepub.com.
Abbreviation: CLABSI, central line–associated bloodstream infection.

Table 2.  Poisson Regression Analysis of CLABSI Rates.a

Group Period Line Days No. of CLABSI Mean Rateb (95% CI) Rate Ratio (95% CI) P Value
Control Baseline 19 072 19 1.00 (0.64-1.56) —  
Control Study 7879 13 1.65 (0.96-2.84) 1.66 (0.80-3.33)c .161
Intervention Baseline 17 258 58 3.36 (2.60-4.35) 3.37 (2.05-5.81)c <.001
Intervention Study 9886 17 1.72 (1.07-2.77) 0.31 (0.13-0.76)d .010

Abbreviation: CLABSI, central line–associated bloodstream infection.

a
Poisson regression model comparing the preceding 2-year period to the study period between the control and intervention groups. The mean
CLABSI rate was significantly lower in the intervention group during the study period than at baseline. The intervention group CLABSI rate also
was significantly lower than predicted as evidenced by the low rate ratio during the study period.
b
Rate of CLABSI per 1000 line days.
c
Compared to baseline rate of control group.
d
Compared to expected rate after correction for baseline rates and change in control.

Results units had a combined CLABSI rate of 0.79 (8/10 096)

CLABSI Rates
During the study period, there were a total of 18 933 line
days for inpatients admitted to the study hospital, with
9886 (52%) in the intervention group. During the preced-
ing year there were 18 864 total line days at the study
hospital. The overall CLABSI rate for the study hospital
during the study period was 1.64 (per 1000 line days)
compared with 1.96 during the preceding year (P = .5).
The CLABSI rate for the intervention group declined
48% between the preceding year and the study period,
from 3.31 (29/8768) to 1.72 (17/9886; χ2 P = .03). Control
during the preceding year, compared to 1.65 (13/7879)
during the study period, representing an increase of 108%
(P = .09). Using Poisson regression, the data were aggre-
gated to simultaneously compare between units and study
periods (Table 2). Expanding the analysis through the
24-month period prior to the study (September 2012 to
August 2014), the control and intervention groups had
baseline CLABSI rates of 1.00 and 3.36, respectively
(3.37-fold difference, P < .001). Comparing these rates to
the study period, the control group had a rise in rate to
1.65 (P = .16). In contrast, the intervention group rate
decreased to 1.72, representing a 69% reduction (P = .01)
Orwoll et al 5
Figure 2.  CLABSI audit rate was lower during the study
period.
Monthly total study hospital independent audits and line days are
compared over the study period (delineated by vertical line) and
preceding year. The number of independent audits per line day was
higher during the preceding year than the study period (0.12 vs 0.06,
P < .01).
Abbreviation: CLABSI, central line–associated bloodstream infection.
when accounting for baseline differences in rate between
the groups and differences between the study period and
baseline as indicated by the control group.
Self-Assessments and Independent Observer
Audits
During the study period, nurses completed a total of 673
self-assessment surveys. Of approximately 200 eligible
nurses in the intervention units, 105 completed 1 or more
self-assessments (median 4, IQR 2-9); 213 (32%) self-
assessments were completed on weekday day shifts,
while 460 (68%) were completed on night shifts or week-
end day shifts. The control units that later implemented
the CLABSI App also participated in contests. These
units engaged another 109 unique nurses and completed
an additional 678 self-assessments.
A total of 522 total independent observer audits were
completed during the study period in intervention units,
and 520 independent observer audits were completed in
control units. In all, 100% of independent audits were
completed on weekdays during day shifts.
Independent observer audits were compared to line
days over time (Figure 2). During the study period, inde-
pendent audits per line day were lower in intervention
units compared with control units at 0.053 (522/9886)
versus 0.066 (520/7879), respectively (P < .01). The rate
of independent audits per line day was twice as high in
the preceding year compared with the study period in
both intervention (0.11 [964/8768], P < .01) and control
(0.13 [1342/10096], P < .01) groups.
Compliance rates for each CLABSI prevention bundle
element were compared between self-assessments and
independent observer audits in the intervention group.
Because the independent auditors could not routinely
observe all 12 bundle elements that were present in the
self-assessment, comparisons were based on the shared 6
core elements (Table 1). In all, 94% (490/522) of inde-
pendent audits were fully compliant with core elements
in intervention units compared with 94% (636/673) of
self-assessments (P = .7). There were no significant dif-
ferences in the compliance rates of any individual core
element between independent audits and self-assessments
in intervention units. The proportion of fully compliant
independent audits was higher in nonintervention units,
at 98% (507/520; P = .004), than in intervention units.
Comparing preceding year to study period, intervention
group independent audit compliance by individual core
element ranged from 97.3% to 100%, with 3 elements
scoring slightly lower during the study period than during
the preceding year (data not shown). Examining the 6 ele-
ments included in the self-assessment but not in the inde-
pendent audit (Table 1, non–underlined elements), each
element had high (>95%) reported compliance except for
patient bathing at 85% (575/673).
Effects of Gamification
Three competitions were held during the study period.
During contest months, nurses in intervention units com-
pleted a total of 534 self-assessments. There were 130
self-assessments completed during the first contest, 38
during the second contest (focused on one unit), and 366
during the third contest. During non–contest months a
total of 139 self-assessments were completed. Contest
months were associated with a significantly higher num-
ber of completed surveys than non–contest months, with
a median of 43 self-assessments/unit/month (IQR 13-122)
versus 2 self-assessments/unit/month (IQR 1-6; P = .03),
respectively (Figure 3a). The median number of unique
nurses completing the CLABSI App was more than 10
times higher during contest months (45 nurses/month
[IQR 19-73]) than during non–contest months (3 nurses/
month [IQR 1-6]; P = .02) (Figure 3b).
Discussion
This study determined that a bundled intervention includ-
ing social gamification integrated with in-context micro-
learning engages nurses with institutional central line care
best practices for CLABSI prevention. This engagement
was associated with a reduction in CLABSI rates in a qua-
ternary care setting. These findings were especially signifi-
cant considering the potential disruptive effect of the move
to a new facility midway through the study, and suggest
that improved nurse engagement may result in improved
outcomes even when compliance monitoring is relatively
reduced (Figure 2). The intervention group CLABSI rate
declined by 48% compared to the preceding year, and was
6 American Journal of Medical Quality 00(0)

Figure 3.  CLABSI app competitions are associated with increased engagement.
Total completed self-assessment (SA) surveys (a) and unique users (b) by month during the study period. Grey bars indicate contest months
(months 1, 10, 11). Total completed surveys (P = .03) and number of distinct users (P = .02) were significantly higher during contest months than
non–contest months.
Abbreviation: CLABSI, central line–associated bloodstream infection.

69% lower than expected after adjustment for differences
in control group CLABSI rate between the study period
and baseline. Based on simple extrapolation of the preced-
ing year rates to the total line days observed during the
study period, the intervention group had 16 fewer CLABSI
than expected. This represents an estimated prevention of 3
deaths and more than 300 inpatient hospital days, with a
savings of more than $1 million, even after accounting for
the costs to develop the CLABSI App and implement the
social gamification system.9-11,24,25
As health care complexity and costs continue to rise,
there is growing pressure on hospitals to develop new
solutions to bring operational efficiency and deliver bet-
ter outcomes at a lower price. Knowledge exists to inform
practice improvements, but too often is not applied to the
care actually delivered.6 Four key elements for hospital
process improvement include leadership declaration of
goals, QI infrastructure, engagement of frontline care
providers, and transparent reporting of performance.26
Today’s hospital workers are accustomed to social media,
gaming, on-demand video, and mobile devices in their
personal lives.7 Though a recent study examined the
effects of gamification on hand hygiene,27 the study team
believes this study reducing CLABSI is the first to report
the formal application of social gamification and in-con-
text microlearning to engage the hospital workforce and
drive process improvement in a key hospital quality per-
formance metric.
The landmark Keystone Project dramatically reduced
CLABSI through the application of a 5-step checklist and
a comprehensive interprofessional unit-based safety pro-
gram (CUSP) in each participating center.28 Though suc-
cessful, the CUSP requires significant longitudinal time
commitment from management. Cincinnati Children’s
Hospital subsequently implemented a successful QI col-
laborative targeting CLABSI, with a stronger focus on
the specific elements of the catheter maintenance bundle,
including a nursing compliance self-reporting tool.29 As a
paper-based tool, however, real-time assessment and
scale are limited. Stanford Children’s reduced CLABSI
through an electronic health record (EHR)–enhanced
checklist linked to a unit-wide real-time display of
Orwoll et al 7
nursing adherence—an attribute of gamification.30
Unfortunately, costs of dedicated monitor displays and
EHR-specific modules similarly limit scale.
The strengths of the present study include its con-
trolled design, which is relatively uncommon in qual-
ity improvement initiatives. Other strengths include
the robust numbers of line days and the reduction in
CLABSI despite the disruptive effects associated with
the move to a new facility. Learning from the limita-
tions of prior CLABSI prevention strategies, this
cloud-based digital app combined a self-assessment
checklist with just-in-time text and video microlearn-
ing. This integrated approach transformed the self-
assessment from simply a compliance tool to a
real-time QI/educational initiative, encouraging fidel-
ity of practice. A social gamification strategy, includ-
ing real-time displays of individual and aggregate team
performance together with formalized contests, drove
voluntary participation by nurses on all shifts, includ-
ing nights and weekends. With a digital social experi-
ence independent of EHR and PHI, scale within and
across institutions is readily possible. This bundled
intervention approach of gamification and microlearn-
ing for engagement in QI (GAMEQI) may be applied
to other HACs or key performance metrics that are
dependent on broad frontline adoption of a standard
practice, aligning with the goals of the CMS Partnership
for Patients’ Hospital Engagement Networks.31
A notable finding in this study was that CLABSI rates
in the intervention group fell significantly despite the fact
that CLABSI prevention bundle compliance rates, as
measured by independent observer audits, did not
increase. Independent audit individual element compli-
ance rates in the intervention group, all already ≥98.8% in
the preceding year, decreased marginally during the study
period on 3 bundle elements. Additionally, the study
period independent audit overall compliance rates were
slightly lower in the intervention group (94%) than the
control group (98%). Independent audit frequency was
decreased in the study period in both intervention and
control groups, and independent audits only assessed
weekday day shift nursing performance. These findings
suggest that, even after achieving high measured compli-
ance with HAI prevention bundles, additional perfor-
mance improvement and clinical benefit can be gained by
increasing nursing engagement through self-assessment
and gamification strategies.
In this study, nursing staff demonstrated broad engage-
ment with the gamified self-assessment competitions,
with participation spread across all nursing shifts.
Competitions also exposed significantly more individual
nurses to in-context microlearning of CLABSI prevention
best practices. Ongoing education of providers has been
reported as a critical component for success in CLABSI
reduction efforts in high-risk pediatric populations,32 and
the study team believes engagement in this process led to
improved fidelity in practice and the resultant decrease in
CLABSIs observed among the intervention units in this
study.
A crucial question in the evaluation of QI efforts such
as these relates to sustainability. The CLABSI App
deployed the first in-context microlearning video for
nurses at the study hospital. CLABSI self-assessments
and microlearning content continued to be available to
nurses and other staff after the study, and one additional
CLABSI self-assessment competition was held. In the
12 months following the study period, intervention units
had a combined CLABSI rate of 1.4, while control units
had a rate of 2.2 per 1000 line days. Neither rate was
significantly different from the respective rates mea-
sured during the study period. These findings suggest
that the effects of this intervention could be sustained
over longer time scales, and the study team supports
future expansion and evaluation of this CLABSI reduc-
tion strategy among other high-risk populations. Based
on management and staff feedback to this approach in
the year since conclusion of this study, the study hospi-
tal has created and deployed another 10+ microlearning
videos through the same social collaboration system.
Furthermore, the study hospital has now applied the
GAMEQI approach to Clostridium difficile infection,
another HAI for which broad staff engagement is essen-
tial for prevention.
This study was limited by the lack of randomization at
the unit or patient level, and the inability to control for
specific patient risk factors within the study groups.
Therefore, causality cannot be attributed directly to this
intervention. If indeed this bundled intervention caused
the reduction in CLABSI, the study team cannot distin-
guish the extent to which impact was driven by self-
assessments, just-in-time microlearning, or social
gamification. In the current technological environment, it
is possible, and likely, that many computer-based quality
and engagement efforts will include multiple elements,
some of which will be difficult to examine individually.
Measured CLABSI bundle compliance during the pre-
ceding year was very high, and thus it would be difficult
to associate major improvements in infection rates with
that metric. Unfortunately, the team also was unable to
track utilization of the microlearning components of the
CLABSI App, though this would be technically possible
in future iterations. Future efforts may address these chal-
lenges through informatics approaches, such as data
aggregation of individual bundle elements and educa-
tional components, over time or across institutions, to
parse the impact of each. The study findings also are
8 American Journal of Medical Quality 00(0)
limited to a single population and setting, and warrant
further validation in other populations and with addi-
tional preventable conditions.
With the rapid growth of social media and mobile tech-
nology, our youth and entering workforce expect on-
demand content and learning. There is a growing gap
between traditional educational establishments and the
modes of learning and communication occurring in the
everyday world.33 Gaming can provide adult learners with
clearly defined goals and application to real-life problems
consistent with Knowles’ theory of adult learning.34
Gaming encourages involvement of all learners and
enhances engagement with content. Moreover, gaming
can aid learner self-awareness by promoting peer interac-
tion and providing feedback.35 However, rigorous evalua-
tion, especially with process of care and patient outcomes,
has been limited.36,37 To meet the quality and economic
challenges of today, health care must reach out across
industries and adapt successful approaches and technolo-
gies. There is a pressing need for health care to explore
novel approaches such as GAMEQI—to take frontline
staff from passive, disconnected consumers of training to
active, social participants in continuous process improve-
ment. Digital transformation of health care quality is not
optional—it is essential.
Acknowledgments
Icons for Figure 1 designed by Freepik and Icomoon from
www.flaticon.com.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of
this article: In 2016, the year following completion of the study,
Dr Roy-Burman left his clinical position to cofound a digital
health start-up, Elemeno Health, which is focused on frontline
staff engagement and on-demand best practices. The remaining
authors declared there are no conflicts of interest.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Institutional funding from the study hospital was provided for
the development of the CLABSI App as well as for competition
prizes. An institutional Tech Transformation Grant (Orwoll,
Roy-Burman) provided partial funding for educational video
production.
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