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Explaining Matching Michigan: an ethnographic study of a patient safety program
Open accessAbstract
BACKGROUND: Quality and safety improvement initiatives in healthcare often display two disconcerting effects. The first is a failure to outperform the secular trend. The second is the decline effect, where an initially promising intervention appears not to deliver equally successful results when attempts are made to replicate it in new settings. Matching Michigan, a patient safety program aimed at decreasing central line infections in over 200 intensive care units (ICUs) in England, may be an example of both. We aimed to explain why these apparent effects may have occurred. METHODS: We conducted interviews with 98 staff and non-participant observation on 19 ICUs; 17 of these units were participating in Matching Michigan. We undertook further telephone interviews with 29 staff who attended program training events and we analyzed relevant documents. RESULTS: One Matching Michigan unit transformed its practices and culture in response to the program; five boosted existing efforts, and 11 made little change. Matching Michigan's impact may have been limited by features of program design and execution; it was not an exact replica of the original project. Outer and inner contexts strongly modified the program's effects. The outer context included previous efforts to tackle central line infections superimposed on national infection control policies that were perceived by some as top-down and punitive. This undermined engagement in the program and made it difficult to persuade participants that the program was necessary. Individual ICUs' histories and local context were also highly consequential: their past experience of quality improvement, the extent to which they were able to develop high quality data collection and feedback systems, and the success of local leaders in developing consensus and coalition all influenced the program's impact on local practices. CONCLUSIONS: Improved implementation of procedural good practice may occur through many different routes, of which program participation is only one. The 'phenotype' of compliance may therefore arise through different 'genotypes.' When designing and delivering interventions to improve quality and safety, risks of decline effects and difficulties in demonstrating added value over the secular trend might be averted by improved understanding of program mechanisms and contexts of implementation.
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“Initiatives to improve quality and safety in healthcare all too frequently result in limited changes for the better or no meaningful changes at all, and the few that are successful are often hard to sustain or replicate in new contexts.1”
From Demystifying theory and its use in improvement (2015) · cites this paper as [1]
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“Initiatives to improve quality and safety in healthcare all too frequently result in limited changes for the better or no meaningful changes at all, and the few that are successful are often hard to sustain or replicate in new contexts.1”
From Demystifying theory and its use in improvement (2015) · cites this paper as [1]
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Clay‐Williams, R., & Colligan, L. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2015-003957 · Cited by 196
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“These findings are aligned with those of other multisited implementation studies in which similar champion characteristics and contexts are found to be necessary mechanisms for driving local practice change [39, 40].”
ResultEffect of an automated notification system for deteriorating ward patients on clinical outcomes
Subbe, C. P., Duller, B., & Bellomo, R. (2017) · Critical Care · doi:10.1186/s13054-017-1635-z · Cited by 190
“surgical, obstetric and pediatric patients) and in other health care settings to tease out how much our findings are context dependent [29].”
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Self-citationAnalysis of cluster randomised stepped wedge trials with repeated cross-sectional samples
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“But attempts to change the status quo in these settings should be informed by a sound evidence base, attention to unintended consequences and recognition of the influence of local histories.(32) Though the volume of research on patient safety in low-income countries is now increasing,(33) 34 little is known about whic…”
BackgroundSelf-citationImpact of the World Health Organization Surgical Safety Checklist on Patient Safety
Haugen, A. S., Sevdalis, N., & Søfteland, E. (2019) · Anesthesiology · doi:10.1097/aln.0000000000002674 · Cited by 172
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“The influence of hierarchies and peer influence on antibiotic prescribing in hospitals[5,10], with the need for tailoring interventions to the context in which they are to be implemented and ensure local ownership[11].”
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Applying ethnography to the study of context in healthcare quality and safety
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Self-citationon behalf of the EPOCH trial group, Stephens, T., Peden, C. J., Pearse, R. M., Shaw, S. E., Abbott, T. E. F., Jones, E. L., Kocman, D., & Martin, G. P. (2018) · Implementation Science · doi:10.1186/s13012-018-0823-9 · Cited by 127
“Building and maintaining effective social relationships is time-consuming and challenging, and the uptake of ‘non-technical’ and ‘socio-adaptive’ interventions can be low amongst health professionals [18].”
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“…from manufacturing plants to improve quality and safety in healthcare settings has been a challenge so as a consequence the results sometimes are considered superficial, with no meaningful changes, low rates of success and difficult to replicate (Davidoff et al. 2015; Dixon-Woods et al. 2013).”
What are effective strategies for the implementation of care bundles on ICUs: a systematic review
Borgert, M. J., Goossens, A., & Dongelmans, D. A. (2015) · Implementation Science · doi:10.1186/s13012-015-0306-1 · Cited by 117
“The context in which a programme for quality improvement is launched contributes to different outcomes [83, 85].”
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Antibiotic Stewardship—Twenty Years in the Making
Charani, E., & Holmes, A. H. (2019) · Antibiotics · doi:10.3390/antibiotics8010007 · Cited by 112
“In unsuccessful units, efforts had not been made to engage with and persuade senior consultants to adopt the program [51].”
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“Nevertheless, in the England study, control hospitals achieved results similar to those in intervention hospitals, and the validity of the CLABSI measures varied among hospitals.(17,18) There is limited evidence assessing the long-term sustainability of quality improvement projects.”
ResultWoodcock, T. M., Adeleke, Y., Goeschel, C. A., Pronovost, P. J., & Dixon‐Woods, M. (2020) · BMC Medical Research Methodology · doi:10.1186/s12874-019-0886-6 · Cited by 102
Self-citationCorso, E., Hind, D., Beever, D., Fuller, G., Wilson, M. J. A., Wrench, I., & Chambers, D. (2017) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-017-1265-0 · Cited by 94
de Kraker, M. E. A., Abbas, M., Huttner, B. D., & Harbarth, S. (2017) · Clinical Microbiology and Infection · doi:10.1016/j.cmi.2017.05.019 · Cited by 93
Fifteen years after To Err is Human: a success story to learn from
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Framework for direct observation of performance and safety in healthcare
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“Dixon-Woods et al conducted a qualitative assessment 38 of the ‘Matching Michigan’ project to reduce ICU-acquired CRBSI in England, 36 based on an originally successful intervention conducted in Michigan, USA.”
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“ICUs implementing the same checklist in the UK revealed marked differences between the few ICUs that achieved a reduction in central line-associated bloodstream infections versus the majority that did not [44,45].”
BackgroundResultGilhooly, D., Green, S. A., McCann, C., Black, N. A., & Moonesinghe, R. (2019) · Implementation Science · doi:10.1186/s13012-019-0894-2 · Cited by 82
“Measurement of compliance is an important aspect of care bundle implementation: [3] it is not sufficient to introduce a change and expect it to be fully adopted into routine practice and to attribute improved outcomes to them [39].”
BackgroundMyths and realities of training in obstetric emergencies.
Draycott, T. J., Collins, K. J., Crofts, J. F., Siassakos, D., Winter, C., Weiner, C. P., & Donald, F. (2015) · Best Practice & Research Clinical Obstetrics & Gynaecology · doi:10.1016/j.bpobgyn.2015.07.003 · Cited by 64
Making implementation science more real
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“But in Explaining Matching Michigan [21], one of the enrolled ICUs achieved its outcomes by changing practices and culture in line with the intervention; five strengthened existing practices and 11 did not respond to the package of interventional initiatives.”
Hospital checklists are meant to save lives — so why do they often fail?
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How collaborative are quality improvement collaboratives: a qualitative study in stroke care
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“Given that improvements can be achieved without collaboration [53], and that one study in a single organization reported impressive results in improving stroke care over a four year period [54], it is therefore sensible for a full assessment of the benefits and costs of collaborative working to be made at the outset o…”
BackgroundSelf-citationOvercoming Challenges In Codifying And Replicating Complex Health Care Interventions
Horton, T., Illingworth, J. H., & Warburton, W. (2018) · Health Affairs · doi:10.1377/hlthaff.2017.1161 · Cited by 63
Developing a Measure of Value in Health Care
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“[8] Dixon-Woods M, Leslie M, Tarrant C, Bion J.”
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Barr, J., Paulson, S. S., Kamdar, B. B., Ervin, J. N., Lane-Fall, M. B., Liu, V. X., & Kleinpell, R. M. (2021) · Critical Care Medicine · doi:10.1097/ccm.0000000000005131 · Cited by 58
Unpacking the black box of improvement
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“[6] developed an ex-post theory to explain why a quality improvement project to reduce central venous catheter bloodstream infection was successfully implemented in the context of a cohort of hospitals in Michigan.”
BackgroundA qualitative study of speaking out about patient safety concerns in intensive care units
Tarrant, C., Leslie, M., Bion, J., & Dixon‐Woods, M. (2017) · Social Science & Medicine · doi:10.1016/j.socscimed.2017.09.036 · Cited by 69
“This paper reports data from an ethnographic study of a national programme (Dixon-Woods et al., 2013) to reduce central venous catheter bloodstream infections (CVC-BSIs) in intensive care unit (Bion et al.”
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Tank, T. 2. G. I.-T., Zingg, W., Storr, J., Park, B. J., Ahmad, R., Tarrant, C., Castro‐Sánchez, E., Tomczyk, S. M., Kilpatrick, C., Allegranzi, B., et al. (2019) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-019-0527-1 · Cited by 58
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“In 2013, a similar null outcome was reported for the ‘‘Matching Michigan’’ national improvement which aimed to reduce central venous catheter infections across 223 UK intensive care units.(73,74) Both examples used an intervention with a strong evidence base, but failed to effectively implement the intervention at sca…”
ResultOvercoming the obstacles of implementing infection prevention and control guidelines
Birgand, G., Johansson, A. F., Szilágyi, E., & Lucet, J. C. (2015) · Clinical Microbiology and Infection · doi:10.1016/j.cmi.2015.09.005 · Cited by 51
“Based on the principle that HCAI surveillance should form the cornerstone of IPC, these networks are necessary for helping to implement guidelines at the local level and reduce HCAI rates [18].”
BackgroundInfluentialModels for Intensive Care Training. A European Perspective
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“Improving patient care is not easy and when successful can result in small changes that are hard to maintain and replicate (Dixon-Woods et al., 2013).”
BackgroundFrom spreading to embedding innovation in health care: Implications for theory and practice
Scarbrough, H., & Kyratsis, Y. (2021) · Health Care Management Review · doi:10.1097/hmr.0000000000000323 · Cited by 61
“Comparative analysis of the U.S. and U.K. cases is revealing (Dixon-Woods et al., 2011, 2013).”
BackgroundMethodInfluentialUnrestricted drinking before surgery: an iterative quality improvement study
Rüggeberg, A., & Nickel, E. A. (2022) · Anaesthesia · doi:10.1111/anae.15855 · Cited by 50
“It may be perceived as ``what you have done so far may be wrong ́ ́ or ``people do not appreciate what you have been doing for the last years ́ ́ [17].”
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“3 translate easily into other contexts [9].”
Portela, M. C., Lima, S. M. L., Martins, M. S., & Travassos, C. (2016) · Cadernos de Saúde Pública · doi:10.1590/0102-311x00105815 · Cited by 64
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“33 In accordance with the rationale behind the concordat approach, we do not advocate that other collaborations simply adopt this example of a concordat ‘ as is ’ .”
BackgroundSelf-citationBreckenridge, J. P., Gray, N., Toma, M., Ashmore, S., Glassborow, R., Stark, C. R., & Renfrew, M. J. (2019) · BMJ Open Quality · doi:10.1136/bmjoq-2018-000553 · Cited by 57
“InTroducTIon Initiating and sustaining effective change in healthcare is a continuing challenge, with even the most successful improvements often being difficult to sustain or replicate in other contexts.(1) Key figures in improvement science have emphasised the importance of learning from the psychological, social an…”
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Lane-Fall, M. B., L., J. L. P., Massa, S., Collard, M. L., Peifer, H. G., Taranti, L. J. D., Linehan, M., Fleisher, L. A., & Barg, F. K. (2018) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2018.02.004 · Cited by 44
The Positive Deviance Approach
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“Overall, environmental, behavioural and organisational contexts of care delivery are broadly acknowledged to influence both the quality and safety of the care delivered (Berenholtz et al., 2014; Dixon-Woods et al., 2013; Edmondson et al., 2016; Kalisch et al., 2007).”
BackgroundTaylor, N. J., Healey, E., Morrow, A., Greening, S., Wakefield, C. E., Warwick, L., Williams, R., & Tucker, K. (2020) · Implementation Science Communications · doi:10.1186/s43058-020-00054-0 · Cited by 41
“and generalisability of interventions problematic [2].”
Bonaconsa, C., Mbamalu, O. N., Mendelson, M., Boutall, A., Warden, C., Rayamajhi, S., Pennel, T. C., Hampton, M. I., Joubert, I., Tarrant, C., et al. (2021) · BMJ Quality & Safety · doi:10.1136/bmjqs-2020-012372 · Cited by 40
Self-citationEliminating Infections in the ICU: CLABSI
Latif, A., Halim, M. S., & Pronovost, P. J. (2015) · Current Infectious Disease Reports · doi:10.1007/s11908-015-0491-8 · Cited by 42
Approaches to Spread, Scale-Up, and Sustainability
Papoutsi, C., Greenhalgh, T., & Marjanovic, S. (2024) · Cambridge University Press eBooks · doi:10.1017/9781009326049 · Cited by 38
Tarrant, C., O’Donnell, B., Martin, G. P., Bion, J., Hunter, A., & Rooney, K. (2016) · Implementation Science · doi:10.1186/s13012-016-0518-z · Cited by 46
“One problem is often a lack of understanding of how interventions actually work and what is required to make them work [29, 30].”
BackgroundSelf-citationA mixed-methods study of challenges experienced by clinical teams in measuring improvement
Woodcock, T. M., Liberati, E. G., & Dixon‐Woods, M. (2019) · BMJ Quality & Safety · doi:10.1136/bmjqs-2018-009048 · Cited by 39
Self-citationStokes, T., Tumilty, E., Doolan‐Noble, F., & Gauld, R. D. C. (2018) · BMJ Open · doi:10.1136/bmjopen-2018-025094 · Cited by 38
“Others have similarly shown the importance of the local context in determining whether local implementation works or fails when rolling out a national quality improvement programme in secondary care.(24) We therefore consider that the implication of our work for future implementers of HealthPathways and similar comple…”
BackgroundMiddleton, S., Lydtin, A., Comerford, D., Cadilhac, D. A.-M., McElduff, P., Dale, S., Hill, K. M., Longworth, M., Ward, J., Cheung, N. W., et al. (2016) · BMJ Open · doi:10.1136/bmjopen-2016-011568 · Cited by 38
“While central venous catheter bloodstream infections dropped in the UK ICUs, the Matching Michigan study was not an exact replica of the original Michigan Keystone project, particularly in terms of implementation of the intervention.(16) As reported elsewhere,(17) our team previously developed a successful implementat…”
ResultCommissioning mental health services
Kisely, S. R. (1997) · Journal of Epidemiology & Community Health · doi:10.1136/jech.51.3.342-b · Cited by 40
Sendlhofer, G., Lumenta, D. B., Leitgeb, K., Kober, B., Jantscher, L., Schanbacher, M., Berghold, A., Pregartner, G., Brunner, G. A., Tax, C., et al. (2016) · PLoS ONE · doi:10.1371/journal.pone.0149212 · Cited by 37
“Nevertheless, in order to prove team performance with respect to SSC-usage, audits in an OR are needed to further investigate the possible disconnection between physical completion of the SSC and actual compliance to checklist items.”
BackgroundInfluentialSheard, L., Marsh, C., Mills, T., Peacock, R., Langley, J., Partridge, R., Gwilt, I., & Lawton, R. (2019) · Health Services and Delivery Research · doi:10.3310/hsdr07360 · Cited by 37
de Mheen, P. J. M., & van Bodegom‐Vos, L. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2014-003787 · Cited by 38
Szymczak, J. E. (2018) · BMJ Quality & Safety · doi:10.1136/bmjqs-2018-008512 · Cited by 35
Leadership and management for infection prevention and control: what do we have and what do we need?
Gould, D. J., Gallagher, R., & Allen, D. A. (2016) · Journal of Hospital Infection · doi:10.1016/j.jhin.2016.07.005 · Cited by 34
Opportunities for system level improvement in antibiotic use across the surgical pathway
Charani, E., Ahmad, R., Tarrant, C., Birgand, G., Leather, A. J. M., Mendelson, M., Moonesinghe, R., Sevdalis, N., Singh, S. K., & Holmes, A. H. (2017) · International Journal of Infectious Diseases · doi:10.1016/j.ijid.2017.04.020 · Cited by 34
Self-citationSubbe, C. P., Tellier, G., & Barach, P. R. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-047446 · Cited by 36
Mann, C., Shaw, A. R. G., Guthrie, B., Wye, L., Man, M., Hollinghurst, S. P., Brookes, S. T., Bower, P., Mercer, S. W., & Salisbury, C. (2016) · BMJ Open · doi:10.1136/bmjopen-2016-011260 · Cited by 32
“If there is a clear trend towards initiatives that are very similar to 3D, any improvements in care resulting from 3D may be matched by those that occur as a result of ‘secular trends’.(29) It is also expected that the various components of the intervention may not be uniformly implemented across practices, in part du…”
BackgroundClinical Communities at Johns Hopkins Medicine: An Emerging Approach to Quality Improvement
Gould, L. J., Wachter, P., Aboumatar, H. J., Blanding, R. J., Brotman, D. J., Bullard, J. E., Gilmore, M. M., Golden, S. H., Howell, E. E., Ishii, L. E., et al. (2015) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(15)41050-5 · Cited by 33
de Neef, M., Bakker, L., Dijkstra, S., Raymakers-Janssen, P. A. M. A., Vileito, A., & Ista, E. (2019) · Pediatric Critical Care Medicine · doi:10.1097/pcc.0000000000001862 · Cited by 33
Ziemann, A., Brown, L., Sadler, E., Ocloo, J. E., Boaz, A., & Sandall, J. (2019) · Systematic Reviews · doi:10.1186/s13643-019-1180-8 · Cited by 34
Emergent barriers to the lean healthcare journey: baronies, tribalism and scepticism
Leite, H., Williams, S., Radnor, Z., & Bateman, N. (2022) · Production Planning & Control · doi:10.1080/09537287.2022.2054386 · Cited by 38
“Dixon-Woods et al. (2013) argue that this challenge often brings some disconcerting effects, such as failure to outperform the secular trend and the decline effect when improvements do not deliver equal, successful results during replication in the new context.”
BackgroundResultAveling, E., Martin, G. P., Herbert, G., & Armstrong, N. (2016) · Social Science & Medicine · doi:10.1016/j.socscimed.2016.11.026 · Cited by 32
“Even where interventions prove successful in one context, attempts to replicate positive impacts elsewhere are variable in their results (Dixon-Woods et al., 2013), and often disappointing (Lomas, 2005).”
BackgroundHowells, K., Burrows, M., Amp, M., Brennan, R., Yeung, W.-L., Jackson, S., Dickinson, J., Draper, J., Campbell, S., Ashcroft, D. M., et al. (2021) · International Journal for Equity in Health · doi:10.1186/s12939-020-01364-4 · Cited by 32
Sheard, L., Marsh, C., O'Hara, J. K., Armitage, G., Wright, J., & Lawton, R. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-014558 · Cited by 32
Papoutsi, C., Poots, A. J., Clements, J. T. C., Wyrko, Z., Offord, N., & Reed, J. E. (2017) · Age and Ageing · doi:10.1093/ageing/afx194 · Cited by 32
“However, their use has not always been met with success and transferability across settings has been questioned [7, 8].”
BackgroundMorton, K., MacNeill, S., Sanderson, E., Dixon, P., King, A. J. L., Jenkins, S., Metcalfe, C. D., Shaw, A., Chalder, M., Benger, J. R., et al. (2019) · BMJ Open Respiratory Research · doi:10.1136/bmjresp-2019-000425 · Cited by 31
White, M. C., Daya, L., Karel, F. K. B., White, G., Abid, S., Fitzgerald, A., Mballa, G. A. E., Sevdalis, N., & Leather, A. J. M. (2019) · Anesthesia & Analgesia · doi:10.1213/ane.0000000000004586 · Cited by 30
“Surgical count completed 132 (41)a 51 (16)a 52 (16)a 35 (11)a 48 (15)a 6 (2)a 102 (56)b 60 (33)b 13 (7)b 4 (2)b 3 (2)b 1 (1)b”
InfluentialSegurança do Paciente: criando organizações de saúde seguras
Sousa, P. J. D. S., & Junior, W. V. M. (2014) · Editora FIOCRUZ eBooks · doi:10.7476/9788575415948 · Cited by 32
Collaborative, O. B. O. T. C. C., Subbe, C. P., Kellett, J. G., Barach, P. R., Chaloner, C., Cleaver, H., Cooksley, T., Korsten, E. H. H. M., Croke, E., Davis, E. R., et al. (2017) · BMC Health Services Research · doi:10.1186/s12913-017-2288-y · Cited by 29
“Medical checklists are more likely to follow a predictable course if they make clinical sense to providers, have clearly defined endpoints [38] and actively engage the teams using them [39].”
Segurança do paciente: criando organizações de saúde seguras
Sousa, P., & Mendes, W. (2019) · Editora FIOCRUZ eBooks · doi:10.7476/9788575416426 · Cited by 62
Gould, D. J., Hale, R., Waters, E., & Allen, D. A. (2016) · Journal of Hospital Infection · doi:10.1016/j.jhin.2016.09.015 · Cited by 29
Shojania, K. G., & de Mheen, P. J. M. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2015-004461 · Cited by 33
Haynes, A. S., Brennan, S., Redman, S., Williamson, A. B., Makkar, S. R., Gallego, G., & Butow, P. N. (2017) · Health Research Policy and Systems · doi:10.1186/s12961-017-0234-4 · Cited by 28
“This may be especially important for interventions where participants have involvement in the tailoring and/or delivery of an intervention, since their attitudes towards its content, form and goals are likely to have profound impacts on what is delivered and how it is received [19, 20].”
BackgroundTroughton, R., Mariano, V., Campbell, A., Hettiaratchy, S. P., Holmes, A. H., & Birgand, G. (2019) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-019-0565-8 · Cited by 28
Central-line-associated bloodstream infection burden among Dutch neonatal intensive care units
Jansen, S. J., Broer, S. D. L., Hemels, M. A. C., Visser, D. H., Antonius, T. A. J., Heijting, I., Bergman, K. A., Termote, J. U. M., Hütten, M. C., van der Sluijs, J. P. F., et al. (2023) · Journal of Hospital Infection · doi:10.1016/j.jhin.2023.11.020 · Cited by 27
“Mock before you block”: an in‐built action‐check to prevent wrong‐side anaesthetic nerve blocks
Pandit, J. J., Matthews, J., & Pandit, M. (2016) · Anaesthesia · doi:10.1111/anae.13664 · Cited by 27
Metadata
- Authors
- Dixon-Woods, M., Leslie, M., Tarrant, C., & Bion, J.
- Affiliations
- Johns Hopkins University (US)
- University of Leicester (GB)
- Queen Elizabeth Hospital Birmingham (GB)
- Venue
- Implementation Science
- Published
- 2013-06-20
- Volume
- 8
- Issue
- 1
- Pages
- 70-70
- ISSN
- 1748-5908 (ISSN-L)
- PMC
- PMC3704826
- OpenAlex
- W2153352637
- Cited by
- 291
- References
- 28
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 18 · 2023: 21 · 2022: 23 · 2021: 18 · 2020: 25 · 2019: 57 · 2018: 21 · 2017: 25 · 2016: 29 · 2015: 30 · 2014: 12 · 2013: 4
- FWCI
- 45.28
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Implementation Science (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Figshare (submittedVersion, cc-by)
- Leicester Research Archive (University of Leicester) (submittedVersion, cc-by)
- Funders
- Wellcome Trust (097899, 097899/A/11/Z)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare Quality and Management
- Keywords
- patient safety programs, central line-associated bloodstream infection, intensive care unit, quality improvement, decline effect, secular trends, program implementation, context effects, infection control, employee engagement, local leadership, intervention replication
- MeSH terms
- Anthropology, Cultural, Catheterization, Central Venous, Critical Care, Cross Infection, England, Humans, Infection Control, Catheter-Related Infections, Quality Improvement, Patient Safety
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