infection control and hospital epidemiologyjuly 2010, vol. 31, no. 7
Beyond b: Lessons Learned
from Implementation of the Department
of Veterans Affairs Methicillin-Resistant
Staphylococcus aureus Prevention Initiative
Amanda G. Garcia-Williams, MPH;
LaToya J. Miller, MPH; Kelly H. Burkitt, PhD;
Timothy Cuerdon, PhD; Rajiv Jain, MD;
Michael J. Fine, MD, MSc; John A. Jernigan, MD, MS;
Ronda L. Sinkowitz-Cochran, MPH
To describe the key strategies and potential pitfalls involved with
implementing the Department of Veterans Affairs (VA) Methicillin-
Resistant Staphylococcus aureus (MRSA) Prevention Initiative in a
qualitative evaluation, we conducted in-depthinterviewswithMRSA
Prevention Coordinators at 17 VA b sites at 2 time points during
Infect Control Hosp Epidemiol 2010; 31(7):763-765
In August 2006, the Department of Veterans Affairs (VA)
Methicillin-Resistant Staphylococcus aureus (MRSA) Preven-
tion Initiative was introduced as a pilot program in 17 VA
Medical Centers, also known as b sites.1An MRSA Prevention
Coordinator (MPC) was appointed at each of the b sites to
be responsible for coordinating the implementation of the 4
primary initiative components or bundle elements (Table 1).
After the pilot program had been successfully implemented
in a single unit, the program was expanded across the facili-
ty in each of the b sites, and finally it was expanded nation-
ally throughout the VA Healthcare System to include 153
Although much work has been done to describe the pos-
itive impact of multifaceted evidence-based interventions,
such as those in the VA MRSA Prevention Initiative, on rates
of healthcare-associated infection, less has been done to qual-
itatively describe the process of implementation and the les-
sons learned from such interventions.2-6The following eval-
uation describes the experiences and lessons learned from the
17 b sites, which will inform facilities both in the VA Health-
care System and beyond.
In-depth interviews were conducted with the MPCs or in-
terim designees at the 17 VA Medical Center b sites at baseline
(after the August 2006 implementation kick-off) and at fol-
low-up (after the March 2007 facility-wide expansion). Eight
of these sites were located in the Northeast (New York and
Pennsylvania), 7 in the South (Delaware, Florida, Kentucky,
Texas, Maryland, and West Virginia), and 2 in the West (Ar-
izona and California). Participants were interviewed using a
structured script of open- and closed-ended questions, al-
lowing for multiple answers if necessary. Interviews were con-
ducted by telephone, and answers to the questions were both
transcribed in real time by the interviewer andaudiorecorded.
Qualitative answers were coded and themes aggregated. De-
scriptive statistics and frequencies were calculated using Excel
A total of 17 facilities (ie, all of the b sites) participated in
both the baseline and follow-up in-depth interviews. At base-
line, most interviewees (88%) described themselves asinterim
designees, and more than one-half (60%) shared their re-
sponsibility with another person. Although most interviewees
were also the hospital’s infection control professionals (81%),
only 10% reported that their other responsibilities changed
to accommodate the new workload.
The position of MPC or interim designee was described
as a clinical rather than an administrative position by 94%
of respondents at baseline and by 72% at follow-up. At base-
line, more than one-half (59%) of the respondents reported
daily participation in MRSA prevention–relatedactivities,and
MPCs spent a mean of 22 hours per week (range, 7–50 hours/
week) on the project. Most (69%) of the baseline respon-
dents did not perceive the amount of time spent on the proj-
ect as adequate, and most stated that a full-time position was
The main responsibilities of the MPC that were reported
at baseline were general coordination of the project (19%),
education and training (16%), and data collection, obtaining
swab samples, and surveillance (15%). In addition, respon-
dents reported data entry (11%), data analysis (10%), and
day-to-day troubleshooting (10%) as a primaryresponsibility.
These responsibilities were similar to those reportedatfollow-
up, with data collection (20%), education and training(17%),
and other duties as needed (16%) topping the list. At follow-
up, data collection (82%) was the one activity that the MPCs
reported engaging in most, whereas education(35%)anddata
feedback to unit staff (24%) were perceived to be the most
important aspect of the position.
Barriers encountered by the MPCs at baseline included the
following: (1) lack of staff engagement and/or resistance to
change (39%), (2) supply issues (eg, stocking isolation gowns,
restocking supplies, or access to supplies and/or equipment)
(15%), and (3) data collection and/or entry and/or analysis
(12%). Similarly, at follow-up, when respondents were asked
about major barriers to implementing the program beyond
the pilot unit, they identified busy and/or overwhelmed staff
(18%), staff resistance (18%), and supply issues (18%).
Facilitators to the MPC’s ability to function successfully at
764infection control and hospital epidemiologyjuly 2010, vol. 31, no. 7
Resistant Staphylococcus aureus (MRSA) Prevention Initiative
Four Components of the Veterans Affairs Methicillin-
1. Active surveillance and/or screening
On admission, patients will undergo collection of nares swab
These are screening cultures. They are not linked to infection
or disease but rather are used to identify MRSA coloniza-
tion or infection in patients in an attempt to break the
chain of transmission. Upon discharge, patient cultures for
MRSA will be performed.
2. Contact precautions
If patients are found to be MRSA positive, they will be placed
under contact precautions, as defined by the Centers for
Disease Control and Prevention.
Management will ensure that adequate supplies for contact
precautions are conveniently available for healthcare work-
ers, to avoid situations in which care is compromised by
lack of supplies for contact precautions.
Patients will remain under contact precautions while in the
hospital unless they become MRSA negative.
Patients who remain MRSA positive on discharge will be
flagged for contact precautions if they are readmitted to the
hospital. They will remain flagged until testing indicates
they are MRSA negative.
In general, attempts at MRSA decolonization are not part of
this MRSA initiative.
3. Hand hygiene
Because hand hygiene is critical to preventing transmission of
MRSA, the present “Infection, Don’t Pass It On” campaign
should be an integral part of the bundle.
Particular attention is to be paid to hand hygiene for health-
care workers, including adherence to hand hygiene before
and after each patient contact.
4. Culture change
As these efforts gain momentum, it should be the goal to
nurture culture change to ensure that infection prevention
and control is everyone’s job and is thus a natural compo-
nent of care at each patient encounter each day.
These components are taken from the Veterans Affairs Directive
baseline included having a previously established positive re-
lationship with staff (33%), having central program office
support (13%), and having the resources available to perform
the functions of the position (13%). At follow-up, respon-
dents reported that communication with and among staff
(24%) and identification of an MRSA champion on each unit
(19%) facilitated expansion of the program beyond the pilot
unit. Furthermore, on a scale of 1 to 5 (with 1 being “strongly
disagree” and 5 being “strongly agree”), respondents at fol-
low-up reported receiving support from their direct super-
visor (mean, 4.2) and somewhat less from their executive
leadership (mean, 3.5). In general, the follow-up participants
perceived some personal authority to implement staff ideas
(mean, 3.8), to implement new practices (mean, 3.7), and to
remove barriers (mean, 3.6).
Baseline respondents reported that there were several per-
ceived barriers to the start-up of the implementation team,
including time and/or logistics (46%) and staff commitment
and/or participation (23%). The primary facilitator to the
start-up of the local MRSA implementation team was open,
cooperative, and/or willing members (69%). The members
7.9 hours/week), unit nursing (mean, 5.6 hours/week), lab-
oratory (mean, 5.4 hours/week), environmental management
and/or housekeeping (mean, 4.0 hours/week), and medical
staff and/or physician champion (mean, 3.5 hours/week). The
primary members of the implementation team who were re-
ported at follow-up were similar to those who devoted the
most time at baseline, with infection control (82%), unit
nursing staff (82%), environmentalmanagementteam(77%),
and laboratory (71%) most often represented.
Finally, follow-up participants were asked about the use of
cultural transformation approaches in the implementation of
the MRSA prevention program. Most respondents (65%) had
used a cultural transformation approach and reported still
using it (85%) at the time of the interview. The majority
chose Positive Deviance (83%) as the cultural transformation
approach because of its front-line staff focus and the success
of the program offices who used it. Other approaches used
were Six Sigma, because of the MPCs’ familiarity with it, and
a combination of Positive Deviance and Six Sigma, because
of a desire to customize the approach. The majority (81%)
of participants believed that using a cultural transformation
approach was necessary for the MRSA program to succeed,
because using it helped to achieve staff buy-in (44%), to
change attitudes and/or behavior (17%), and to promote staff
involvement (17%). Despite the perceived importance of in-
corporating this approach, participants responded neutrally
(mean, 3.7 on the previously described scale of 1 to 5) when
asked if they believed a cultural transformation had taken
place at their facility after implementation.
The barriers and facilitators to implementation that were re-
ported by the MPCs were consistent with the findings of
previous studies and suggest that facilities may need more
organization-level support and front-line staff buy-in.4,7-10Al-
though cultural transformation approaches were widely used
in the VA MRSA Prevention Initiative and were perceived to
be important, culture change may have been occurring only
at the staff and/or unit level, not across the facility. Without
organizational support (eg, providing resources such as time
and supplies) from the leadership, a coordinator may not be
able to fulfill all of the duties, and the program’s implemen-
tation may be jeopardized.7-10
There were some limitations to this study. All answers were
self-reported, with no direct observations conducted to verify
individual practices or organizational policies. Also, respon-
dents at baseline and follow-up were not always the same,
beyond b: lessons learned 765
and therefore, changes over time may be attributed to the
differing perceptions between the changing MPCs. Nonethe-
less, there are several lessons to be learned from this evalu-
ation of the VA MRSA Prevention Initiative that may be
generalizable to future prevention initiatives, both in the VA
Healthcare System and beyond.
Potential conflicts of interest.
evant to this article.
All authors report no conflicts of interest rel-
From the Division of Healthcare Quality Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia (A.G.G.-W., J.A.J., R.L.S.-C.); Cen-
ter for Health Equity Research and Promotion (K.H.B., M.J.F.), Veterans
Affairs Pittsburgh Healthcare System (L.J.M., R.J.), and Division of General
Internal Medicine, Department of Medicine, University of Pittsburgh
(M.J.F.), Pittsburgh, Pennsylvania; and the Office of Quality and Perfor-
mance, Veterans Affairs Central Office, Washington, DC (T.C.).
Address reprint requests to Ronda L. Sinkowitz-Cochran, MPH, Centers
for Disease Control and Prevention, Division of Healthcare Quality Pro-
motion, 1600 Clifton Road MS A-31, Atlanta, GA 30333 (RLS7@cdc.gov).
Received November 2, 2009; accepted January 12, 2010; electronically
published May 28, 2010.
The findings and conclusions in this report are those of the authors and
do not necessarily represent the official position of the Centers for Disease
Control and Prevention.
? 2010 by The Society for Healthcare Epidemiology of America. All rights
reserved. 0899-823X/2010/3107-0016$15.00. DOI: 10.1086/653818
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