Exemplary Clinical Practice
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Infection Prevention Achievements
In 2024, our infection prevention team made significant strides in improving patient outcomes across the hospital through structured, collaborative, and data-driven initiatives. Central to these achievements was the implementation of targeted quality improvement strategies, deepened engagement across multidisciplinary teams, and meaningful education efforts that fostered a culture of safety and accountability.
Targeted CLABSI and CAUTI Reduction Efforts
The Central Line-Associated Bloodstream Infection (CLABSI) and the Catheter Associated Urinary Tract Infection (CAUTI) workgroups launched their first Plan-Do-Study-Act (PDSA) cycle, empowering unit-based teams to identify unique challenges and implement tailored interventions. This grassroots approach was guided by comprehensive gap analyses and the use of Ishikawa (fishbone) diagrams to explore the root causes of CLABSI and CAUTI events. Through this structured root cause analysis and collaborative input, the workgroup developed unit-specific strategies that were actively monitored for effectiveness. One key deliverable was the creation and dissemination of two educational fliers reinforcing the components of the CLABSI and CAUTI prevention bundles, ensuring consistent practice across care teams.
Enhanced Testing and Surveillance
Infection prevention efforts extended to laboratory testing practices with the successful transition to a two-step testing process for Clostridioides difficile. This change enabled more accurate identification of patients with C. diff toxin, which, coupled with the improved testing algorithm, resulted in a dramatic drop in reported C. diff rates.
We also expanded our Candida auris (C. auris) surveillance program. In coordination with the Transfer Center, a protocol was implemented to screen all patients being transferred to UWMC. Infection risk indicators were placed directly in patients’ charts, ensuring timely screening and isolation when necessary.
Cross-Departmental Collaboration and Education
Recognizing the critical role of environmental services in infection prevention, we partnered with EVS to provide targeted hand hygiene education during staff meetings. To strengthen compliance monitoring, we launched a new Hand Hygiene Observation Tool, leading to an increase in hand hygiene audits across both campuses. These audits have fostered greater awareness and accountability.
Construction Site Safety and Infrastructure Support
Our team also engaged with Operations & Maintenance and the Design and Construction Management (DCM) to ensure infection prevention standards were upheld at construction sites. These collaborations enhanced the safety of our physical environment and helped mitigate infection risks associated with facility projects.
Workflow Optimization and Vendor Partnerships
We completed multiple workflows in the EPIC system, refining order sets to better support infection prevention practices. Additionally, we partnered with a vendor to deliver unit-based education, ensuring front-line teams received consistent and practical training aligned with best practices.
Measured Impact
Collectively, these initiatives led to an increased awareness by staff of our healthcare associated conditions and a notable reduction in the number of CAUTI and C. diff events in 2024. Our multi-pronged strategy—combining analytics, unit-level empowerment, interdepartmental collaboration, and targeted education—demonstrated that meaningful improvements in infection prevention are possible when a hospital works together as one team, focused on patient safety.
Advancing Patient Safety
In 2024 UWMC achieved improvements in patient safety through collaborative efforts across the organization. The Patient Safety team played a key role in these advancements by fostering interdisciplinary collaboration, leading proactive patient safety risk mitigation, and facilitating quality improvement efforts in our pursuit of zero preventable harm.
In February 2024, we replaced the nearly 20-year-old Patient Safety Net (PSN) with a modernized reporting system, “Safety Net,” designed to provide frontline reporters with a more intuitive experience. Our team continues to support leaders and staff, ensuring a smooth transition.
We also revised our event response policy and implemented systemwide training to improve the documentation of follow-ups on reported safety events. Through weekly audits of Safety Net documentation and direct feedback, we have strengthened compliance.
In 2024, a total of 13, 538 events were reviewed by our team, a 5% increase compared to FY’23.
Our comprehensive, tiered response to patient safety concerns reported in Safety Net led to the escalation of 931 moderate to severe harm events and the completion of 84 intensive reviews of high-harm incidents or high-risk near misses—reflecting a 26% increase compared to FY’23.
Last year, we conducted 84 intensive reviews of events involving significant harm or high-risk near misses. Using a human factors, just culture, and systems-oriented approach to our intensive reviews, we identified 79 underlying systemic contributing causes and collaborated with leaders to implement 291 corrective actions aimed at preventing recurrence.
To sustain these quality improvement efforts, we engaged leadership sponsors for each intensive review to support successful implementation and address potential barriers.
Furthermore, we conducted weekly Leadership Quality and Patient Safety rounding, gaining deeper insight into the challenges faced by frontline teams and collaborating with leadership to address risks to both patient and staff safety.
Lastly, our Patient Safety team honored 29 clinicians and staff at the annual Safety Heroes awards for their exceptional dedication to patient safety and commitment to going above and beyond.
Patient safety is a shared responsibility, impacting everyone in healthcare. Regardless of your role, you play a vital part in ensuring the well-being and safety of our patients.