QAPI 135 - Improved Leadership Engagement and Injection Safety Through Standardized, Structured Action Planning

Background: Ambulatory clinics offer a range of services including vaccinations, administration of medications, and various diagnostic and therapeutic injections. Ensuring safety standards are met is crucial to prevent the transmission of infections and other adverse events. While these standards are well established, opportunities to improve injection safety continue to be identified when conducting direct observations.
Wide variations in healthcare worker (HCW) injection practices have been observed during infection prevention (IP) rounding in a large multi-state health system. Local leaders of these HCWs must submit corrective action plans for IP observations with compliance scores below system thresholds. Low quality action plans have been associated with a greater likelihood of repeated observations and safety events.

Methods: In 2022, system IP leaders adapted well-known SMART Goal frameworks into a novel, standardized template for leaders to create action plans in response to IP observations. The template uses the SMART acronym: specific, measurable, actionable, resources, and time-based. Direct questions under each heading further guide the leader to identify barriers and develop their plan. Compliance scores from injection safety surveillance were compared pre and post SMART Plan implementation.

Results: Ambulatory clinics saw an improvement in injection safety related findings from Q3 2022 to Q3 2023. Multi-dose medication vials being appropriately dated and discarded improved from 82% (Q3 2022) to 88% (Q3 2023). Medication refrigerator temperature monitoring improved from 69% (Q3 2022) to 85% (Q3 2023). Prepared medications being appropriately labeled improved from 60% (Q3 2022) to 87% (Q3 2023). Timeliness and completeness of action plans have also improved in 2023. Action plans are now focused, specific, and have defined ongoing follow up to build resiliency into their process.

Conclusions: Standardized action planning templates are an effective tool to improve injection safety by engaging leaders to create and implement effective action plans resulting in hardwired processes and sustained improvements.