Organizational Improvements Change Mindset to Enhance Patient Safety Semaj Badger-McLendon, BSN, RN, CICStefanie Buchanan, BSN, RN, CICMarilyn Middlebrooks, MSN, RN, CCRN, CICChad Neilsen, MPH, CICMelissa Nelson, BSN, RNMarko Predic, MS,CIC University of Florida Health JacksonvilleJacksonville, Florida The infection prevention team at the University of Florida Health Jacksonville (UFHJ) spearheaded multiple organizational improvements to change culture and enhance patient safety at their facility. As the only level I, academic safety net hospital in the region, UFHJ sees many of the most complex patients. “There was a mindset that we couldn’t do much about infections because our patients are so sick,” said Infection Prevention and Control (IPC) Director Chad Neilsen. In 2014, the facility’s leadership included central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) reductions in the organization’s strategic goals, signaling an increased emphasis on patient safety. An external consultant identified several key IPC challenges, including manual, retrospective infection-data reporting and placement of the IPC department under nursing. Shortly after, the facility shifted the department under the hospital’s quality division and created a new IPC director position. “Our new director provided perspective that enabled us to make key changes,” said IPC team member Stefanie Buchanan. These changes included real-time electronic surveillance and leveraging other technologies –such as a root-cause analysis tool and an app-based program for hand-hygiene surveys — that improved feedback and helped drive timely interventions. The IPC team used data from these systems to determine infection priorities and create multidisciplinary committees focused on individual HAIs. Bedside rounding on all floors helped identify gaps, which staff shared with the committees. “Information filters to the committees in a very fluid way, and they develop plans,” said Buchanan. Finally, UFHJ instituted systems to increase shared accountability. “We needed the units to understand that any single infection can signal opportunities for hospital-wide process improvement,” said Buchanan. Between 2015-2018, UFHJ recorded a 74 percent reduction in CLABSI and an 86 percent reduction in CAUTI. “Celebrate your wins along the way, and it will help maintain the motivation to change,” said Buchanan.