The document provides a summary of milestones in medicine, medical education, hospitals/healthcare systems, public health, and the U.S. health insurance system from 1700-2015. It describes key developments such as the establishment of the first medical school in 1765, the Flexner Report in 1910 which led to standardization of medical education, the creation of Medicare and Medicaid in 1965, and the passage of the Affordable Care Act in 2010. The document also summarizes milestones related to the development of hospitals and healthcare delivery systems over time as well as milestones in public health initiatives and the evolution of the U.S. health insurance system.

1. TABLE 1-1 Milestones of Medicine and Medical Education
1700–2015 ■ 1700s: Training and apprenticeship under one
physician was common until hospitals were founded in the mid-
1700s. In 1765, the first medical school was established at the
University of Pennsylvania. ■ 1800s: Medical training was
provided through internships with existing physicians who often
were poorly trained themselves. In the United States, there were
only four medical schools, which graduated only a handful of
students. There was no formal tuition with no mandatory
testing. ■ 1847: The AMA was established as a membership
organization for physicians to protect the interests of its
members. It did not become powerful until the 1900s when it
organized its physician members by county and state medical
societies. The AMA wanted to ensure these local societies were
protecting physicians’ financial well-being. It also began to
focus on standardizing medical education. ■ 1900s–1930s: The
medical profession was represented by general or family
practitioners who operated in solo practices. A small percentage
of physicians were women. Total expenditures for medical care
were less than 4% of the gross domestic product. ■ 1904: The
AMA created the Council on Medical Education to establish
standards for medical education. ■ 1910: Formal medical
education was attributed to Abraham Flexner, who wrote an
evaluation of medical schools in the United States and Canada
indicating many schools were substandard. The Flexner Report
led to standardized admissions testing for students called the
Medical College Admission Test (MCAT), which is still used as
part of the admissions process today. ■ 1930s: The healthcare
industry was dominated by male physicians and hospitals.
Relationships between patients and physicians were sacred.
Payments for physician care were personal. ■ 1940s–1960s:
When group health insurance was offered, the relationship
between patient and physician changed because of third-party
payers (insurance). In the 1950s, federal grants supported

2. medical school operations and teaching hospitals. In the 1960s,
the Regional Medical Programs provided research grants and
emphasized service innovation and provider networking. As a
result of the Medicare and Medicaid enactment in 1965, the
responsibilities of teaching faculty also included clinical
responsibilities. ■ 1970s–1990s: Patient care dollars surpassed
research dollars as the largest source of medical school funding.
During the 1980s, third-party payers reimbursed academic
medical centers with no restrictions. In the 1990s with the
advent of managed care, reimbursement was restricted. ■ 2014:
According to the 2014 Association of American Medical
Colleges (AAMAC) annual survey, over 70% of medical schools
have or will be implementing policies and programs to
encourage primary care specialties for medical school students.
TABLE 1-2 Milestones of the Hospital and Healthcare Systems
1820–2015 ■ 1820s: Almshouses or poorhouses, the precursor
of hospitals, were developed to serve primarily poor people.
They provided food and shelter to the poor and consequently
treated the ill. Pesthouses, operated by local governments, were
used to quarantine people who had contagious diseases such as
cholera. The first hospitals were built around areas such as New
York City, Philadelphia, and Boston and were used often as a
refuge for the poor. Dispensaries or pharmacies were
established to provide free care to those who could not afford to
pay and to dispense drugs to ambulatory patients. ■ 1850s: A
hospital system was finally developed but hospital conditions
were deplorable because of unskilled providers. Hospitals were
owned primarily by the physicians who practiced in them. ■
1890s: Patients went to hospitals because they had no choice.
More cohesiveness developed among providers because they had
to rely on each other for referrals and access to hospitals, which
gave them more professional power. ■ 1920s: The development
of medical technological advances increased the quality of
medical training and specialization and the economic
development of the United States. The establishment of
hospitals became the symbol of the institutionalization of health

3. care. In 1929, President Coolidge signed the Narcotic Control
Act, which provided funding for construction of hospitals for
patients with drug addictions. ■ 1930s–1940s: Once physician-
owned hospitals were now owned by church groups, larger
facilities, and government at all levels. ■ 1970–1980: The first
Patient Bill of Rights was introduced to protect healthcare
consumer representation in hospital care. In 1974, the National
Health Planning and Resources Development Act required states
to have certificate of need (CON) laws to qualify for federal
funding. ■ 1980–1990: According to the AHA, 87% of hospitals
were offering ambulatory surgery. In 1985, the EMTALA was
enacted, which required hospitals to screen and stabilize
individuals coming into emergency rooms regardless of the
consumers’ ability to pay. ■ 1990–2000s: As a result of the
Balanced Budget Act cuts of 1997, the federal government
authorized an outpatient Medicare reimbursement system. ■
1996: The medical specialty of hospitalists, who provide care
once a patient is hospitalized, was created. ■ 2002: The Joint
Commission on the Accreditation of Healthcare Organizations
(now The Joint Commission) issued standards to increase
consumer awareness by requiring hospitals to inform patients if
their healthcare results were not consistent with typical results.
■ 2002: The CMS partnered with the AHRQ to develop and test
the HCAHPS (Hospital Consumer Assessment of Healthcare,
Providers and Systems Survey). Also known as the CAHPS
survey, the HCAHPS is a 32-item survey for measuring
patients’ perception of their hospital experience. ■ 2007: The
Institute for Health Improvement launched the Triple Aim,
which focuses on three goals: improving patient satisfaction,
reducing health costs, and improving public health. ■ 2011: In
1974, a federal law was passed that required all states to have
certificate of need (CON) laws to ensure the state approved any
capital expenditures associated with hospital/medical facilities’
construction and expansion. The act was repealed in 1987 but as
of 2014, 35 states still have some type of CON mechanism. ■
2011: The Affordable Care Act created the Centers for Medicare

4. and Medicaid Services’ Innovation Center for the purpose of
testing “innovative payment and service delivery models to
reduce program expenditures … while preserving or enhancing
the quality of care” for those individuals who receive Medicare,
Medicaid, or Children’s Health Insurance Program (CHIP)
benefits. ■ 2015: The Centers for Medicare and Medicaid
Services posted its final rule that reduces Medicare payments to
hospitals that have exceeded readmission limits of Medicare
patients within 30 days. TABLE 1-3 Milestones in Public Health
1700–2015 ■ 1700–1800: The United States was experiencing
strong industrial growth. Long work hours in unsanitary
conditions resulted in massive disease outbreaks. U.S. public
health practices targeted reducing epidemics, or large patterns
of disease in a population, that impacted the population. Some
of the first public health departments were established in urban
areas as a result of these epidemics. ■ 1800–1900: Three very
important events occurred. In 1842, Britain’s Edwin Chadwick
produced the General Report on the Sanitary Condition of the
Labouring Population of Great Britain, which is considered one
of the most important documents of public health. This report
stimulated a similar U.S. survey. In 1854, Britain’s John Snow
performed an analysis that determined contaminated water in
London was the cause of a cholera epidemic. This discovery
established a link between the environment and disease. In
1850, Lemuel Shattuck, based on Chadwick’s report and Snow’s
activities, developed a state public health law that became the
foundation for public health activities. ■ 1900–1950: In 1920,
Charles Winslow defined public health as a focus of preventing
disease, prolonging life, and promoting physical health and
efficiency through organized community efforts. During this
period, most states had public health departments that focused
on sanitary inspections, disease control, and health education.
Throughout the years, public health functions included child
immunization programs, health screenings in schools,
community health services, substance abuse programs, and
sexually transmitted disease control. In 1923, a vaccine for

5. diphtheria and whooping cough was developed. In 1928,
Alexander Fleming discovered penicillin. In 1933, the polio
vaccine was developed. In 1946, the National Mental Health Act
(NMHA) provided funding for research, prevention, and
treatment of mental illness. ■ 1950–1980: In 1950, cigarette
smoke was identified as a cause of lung cancer. In 1952, Dr.
Jonas Salk developed the polio vaccine. The Poison Prevention
Packaging Act of 1970 was enacted to prevent children from
accidentally ingesting substances. Childproof caps were
developed for use on all drugs. In 1980, the eradication of
smallpox was announced. ■ 1980–1990: The first recognized
cases of AIDS occurred in the United States in the early 1980s.
1988: The IOM Report defined public health as organized
community efforts to address the public interest in health by
applying scientific and technical knowledge and promote health.
The first Healthy People Report (1987) was published and
recommended a national prevention strategy. ■ 1990–2000: In
1997, Oregon voters approved a referendum that allowed
physicians to assist terminally ill, mentally competent patients
to commit suicide. From 1998 to 2006, 292 patients exercised
their rights under the law. ■ 2000s: The second Healthy People
Report was published in 2000. The terrorist attack on the United
States on September 11, 2001, impacted and expanded the role
of public health. The Public Health Security and Bioterrorism
Preparedness and Response Act of 2002 provided grants to
hospitals and public health organizations to prepare for
bioterrorism as a result of September 11, 2001. ■ 2010: The
ACA was passed. Its major goal was to improve the nation’s
public health level. The third Healthy People Report was
published. ■ 2015: There has been an increase nationally of
children who have not received vaccines due to parents’ beliefs
that vaccines are not safe. As a result, there have been measles
outbreaks throughout the nation even though measles was
considered eradicated decades ago. TABLE 1-4 Milestones of
the U.S. Health Insurance System 1800–2015 ■ 1800–1900:
Insurance was purchased by individuals in the same way one

6. would purchase car insurance. In 1847, the Massachusetts
Health Insurance Co. of Boston was the first insurer to issue
“sickness insurance.” In 1853, a French mutual aid society
established a prepaid hospital care plan in San Francisco,
California. This plan resembles the modern health maintenance
organization (HMO). ■ 1900–1920: In 1913, the International
Ladies Garment Workers began the first union-provided medical
services. The National Convention of Insurance Commissioners
drafted the first model for regulation of the health insurance
industry. ■ 1920s: The blueprint for health insurance was
established in 1929 when J. F. Kimball began a hospital
insurance plan for school teachers at Baylor University Hospital
in Texas. This initiative became the model for Blue Cross plans
nationally. The Blue Cross plans were nonprofit and covered
only hospital charges so as not to infringe on private
physicians’ income. ■ 1930s: There were discussions regarding
the development of a national health insurance program.
However, the AMA opposed the move (Raffel & Raffel, 1994).
With the Depression and U.S. participation in World War II, the
funding required for this type of program was not available. In
1935, President Roosevelt signed the Social Security Act (SSA),
which created “old age insurance” to help those of retirement
age. In 1936, Vassar College, in New York, was the first college
to establish a medical insurance group policy for students. ■
1940s–1950s: The War Labor Board froze wages, forcing
employers to offer health insurance to attract potential
employees. In 1947, the Blue Cross Commission was
established to create a national doctors network. By 1950, 57%
of the population had hospital insurance. ■ 1965: President
Johnson signed the Medicare and Medicaid programs into law. ■
1970s–1980s: President Nixon signed the HMO Act, which was
the predecessor of managed care. In 1982, Medicare proposed
paying for hospice or end-of-life care. In 1982, diagnosis-
related groups (DRGs) and prospective-payment guidelines were
developed to control insurance reimbursement costs. In 1985,
the Consolidated Omnibus Budget Reconciliation Act (COBRA)

7. required employers to offer partially subsidized health coverage
to terminated employees. ■ 1990–2000: President Clinton’s
Health Security Act proposed a universal healthcare coverage
plan, which was never passed. In 1993, the Family Medical
Leave Act (FMLA) was enacted, which allowed employees up to
12 weeks of unpaid leave because of family illness. In 1996, the
Health Insurance Portability and Accountability Act (HIPAA)
was enacted, making it easier to carry health insurance when
changing employment. It also increased the confidentiality of
patient information. In 1997, the Balanced Budget Act (BBA)
was enacted to control the growth of Medicare spending. It also
established the State Children’s Health Insurance Program
(SCHIP). ■ 2000: The SCHIP, now known as the Children’s
Health Insurance Program (CHIP), was implemented. ■ 2000:
The Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act provided some relief from the BBA by providing
across-the-board program increases. ■ 2003: The Medicare
Prescription Drug, Improvement, and Modernization Act was
passed, which created Medicare Part D, prescription plans for
the elderly. ■ 2006: Massachusetts mandated all state residents
have health insurance by 2009. ■ 2009: President Obama signed
the American Recovery and Reinvestment Act (ARRA), which
protected health coverage for the unemployed by providing a
65% subsidy for COBRA coverage to make the premiums more
affordable. ■ 2010: The ACA was signed into law, making it
illegal for insurance companies to rescind insurance on their
sick beneficiaries. Consumers can also appeal coverage claim
denials by the insurance companies. Insurance companies
cannot impose lifetime limits on essential benefits. ■ 2013: As
of October 1, individuals could buy qualified health benefits
plans from the Health Insurance Marketplaces. If an employer
does not offer insurance, effective 2015, consumers can
purchase it from the federal Health Insurance Marketplace. The
federal government provided states with funding to expand their
Medicaid programs to increase preventive services. MARGIN IS
OFF ■ 2015: The CMS posted its final rule that reduces

8. Medicare payments to hospitals that readmit Medicare patients
within 30 days after discharge. This rule is an attempt to focus
hospital initiatives on quality care
Rubic_Print_FormatCourse CodeClass CodeAssignment
TitleTotal PointsNRS-433VNRS-433V-O506PICOT Question
and Literature Search120.0CriteriaPercentage1: Unsatisfactory
(0.00%)2: Less Than Satisfactory (75.00%)3: Satisfactory
(83.00%)4: Good (94.00%)5: Excellent
(100.00%)CommentsPoints EarnedContent80.0%Summary of
Clinical Issue5.0%A clinical issue is omitted or is not relevant
to nursing practice.A clinical issue is partially presented. It is
unclear how the clinical issue relates to nursing practice.
Significant aspects are missing, or there are inaccuracies.A
clinical issue is summarized. The issue generally relates to
nursing practice.A clinical issue is presented. The issue relates
to nursing practice. Minor detail is needed for clarity.A clinical
issue is thoroughly described. The issue relates to nursing
practice.PICOT Question10.0%A PICOT question is not
included.A PICOT question is provided but is incomplete. The
PICOT question format is used incorrectly.A PICOT question is
provided. The PICOT question format is generally applied.
Some information or revision is needed.A PICOT question is
provided. The PICOT question format is applied accurately.
Some detail is need for support or clarity.A PICOT question is
clearly presented. The PICOT question format is applied
accurately and presents an answerable and researchable
question.APA-Formatted Article Citations With
Permalinks5.0%Article citations and permalinks are
omitted.Article citations and permalinks are presented. There
are significant errors in the APA format. One or more links do
not lead to the intended article.Article citations and permalinks
are presented. Article citations are presented in APA format, but
there are errors.Article citations and permalinks are presented.
Article citations are presented in APA format. There are minor
errors.Article citations and permalinks are presented. Article

9. citations are accurately presented in APA format.Relationship
of Articles to the PICOT Question10.0%Three or more articles
do not relate to the PICOT question.At least two articles do not
relate to the PICOT question. The remaining articles provide a
small degree of support for the PICOT question. Different
articles are needed to provide better support for the PICOT
question.At least one articles does not relate to the PICOT
question. The remaining articles provide general support for the
PICOT question. One or two different articles are needed to
provide better support for the PICOT question.Each article
relates to the PICOT question. The articles provide support for
the PICOT question.Each article clearly relates to the PICOT
question. The articles provide strong support for the PICOT
question.Quantitative and Qualitative Articles10.0%Fewer than
six research articles are presented. Four or more articles do not
meet the assignment criteria for a quantitative, qualitative,Six
research articles are presented. Three articles do not meet the
assignment criteria for a quantitative, qualitativeSix research
articles are presented. Two articles do not meet the assignment
criteria for a quantitative, qualitative, or mixed study. Some
ability to identify the type of research design used in a study is
demonstrated.Six research articles are presented. One article
does not meet the assignment criteria for a quantitative,
qualitative, or mixed study. A general ability to identify the
type of research design used in a study is demonstrated.Six
research articles are presented. Each article meets the
assignment criteria for a quantitative, qualitative, or mixed
study. An ability to identify the different types of research
design used in a study is consistently demonstrated.Purpose
Statements5.0%Purpose statements are omitted or are
incomplete overall.Purpose statements are referenced but are
incomplete in some areas.Purpose statements are presented.
There are minor omissions in some areas, or major
inaccuracies.Purpose statements summarized. There are some
minor inaccuracies in some.Purpose statements are accurate and
clearly summarized.Research Questions5.0%Research questions

10. are omitted or are incomplete overall.Research question is
presented for each article. The research question has been
misidentified or misinterpreted for at least two of the articles.
Additional information is needed to fully illustrate the research
question for several of the articles.Research questions are
presented. The research question has been misidentified or
misinterpreted for one of the articles. Some detail is needed to
fully illustrate the research question for one or two
articles.Research questions are presented. Minor detail is
needed for clarity in some areas.Research questions are accurate
and capture the fundamental question posed by the researchers
in each study.Outcome5.0%Research outcomes are omitted or
are incomplete overall.Research outcome is presented for each
article. The research outcome has been misidentified or
misinterpreted for at least two of the articles. Additional
information is needed to fully illustrate the research outcomes
for several of the articles.Research outcomes are presented. The
research outcome has been misidentified or misinterpreted for
one of the articles. Some detail is needed to fully illustrate the
research outcomes for one or two articles.Research outcomes
are presented. Minor detail is needed for clarity in some
areas.Research outcomes are accurate and described in detail for
each article.Setting5.0%The setting is omitted for one or more
of the articles. The setting described for three or more articles
is inaccurate or incomplete.The setting is indicated for each
article. The setting described for two of the articles is
inaccurate or incomplete.The setting is indicated for each
article. The setting described for one article is inaccurate or
incomplete.The setting is indicated for each article. Some detail
is needed to fully illustrate the physical, social, or cultural site
in which the researcher conducted the study.The setting in
which the researcher conducted the study is detailed and
accurate for each article.Sample5.0%The sample is omitted for
one or more of the articles. The sample described for three or
more articles is inaccurate or incomplete.The sample is
indicated for each article. The sample described for at least two

11. of the articles is inaccurate or incomplete.The sample is
indicated for each article. The sample described for one article
is inaccurate or incomplete.The sample is indicated for each
article. Minor detail is needed for accuracy.The sample is
indicated and accurate for each article.Method5.0%Method of
study for one or more articles is omitted. Overall, the methods
of study are incomplete.The method of study is partially
presented for each article. Key information is consistently
omitted. Overall, the methods reported contain inaccuracies.The
method of study for each article is presented. Some key aspects
are missing for one or two articles, or there are some
inaccuracies for the methods reported.A discussion on the
method of study for each article is presented.A thorough
discussion on the method of study for each article is
presented.Key Findings of the Study5.0%Discussion of study
results, including findings and implications for nursing practice,
is incomplete.A summary of the study results includes findings
and implications for nursing practice but lacks relevant details
and explanation. There are some omissions or
inaccuracies.Discussion of study results, including findings and
implications for nursing practice, is generally presented for
each article. Overall, the discussion includes some relevant
details and explanation.Discussion of study results, including
findings and implications for nursing practice, is complete and
includes relevant details and explanation.Discussion of study
results, including findings and implications for nursing practice,
is thorough with relevant details and extensive
explanation.Recommendations of the Researcher5.0%Researcher
recommendations are omitted for one or more of the articles.
The recommendations described for three or more articles are
inaccurate or incomplete.Researcher recommendations are
indicated for each article. The researcher recommendations
described for two of the articles are inaccurate or
incomplete.Researcher recommendations for each article are
presented. Researcher recommendations described for one
article are inaccurate or incomplete.Researcher

12. recommendations for each article are accurately presented.
Minor detail is needed for accuracy.Researcher
recommendations accurate are thoroughly described for each
article.Organization and Effectiveness10.0%Mechanics of
Writing (includes spelling, punctuation, grammar, language
use)10.0%Surface errors are pervasive enough that they impede
communication of meaning. Inappropriate word choice or
sentence construction is used.Frequent and repetitive
mechanical errors distract the reader. Inconsistencies in
language choice (register), sentence structure, or word choice
are present.Some mechanical errors or typos are present, but
they are not overly distracting to the reader. Correct sentence
structure and audience-appropriate language are used.Prose is
largely free of mechanical errors, although a few may be
present. A variety of sentence structures and effective figures of
speech are used.Writer is clearly in command of standard,
written, academic English.Format10.0%Documentation of
Sources (citations, footnotes, references, bibliography, etc., as
appropriate to assignment and style)10.0%Sources are not
documented.Documentation of sources is inconsistent or
incorrect, as appropriate to assignment and style, with numerous
formatting errors.Sources are documented, as appropriate to
assignment and style, although some formatting errors may be
present.Sources are documented, as appropriate to assignment
and style, and format is mostly correct.Sources are completely
and correctly documented, as appropriate to assignment and
style, and format is free of error.Total Weightage100%
As you begin your Literature Review search for the Week 1
assignment, I want to share some information with you to assist
you in knowing the difference. This is very important. The
Week 1 paper, sets the course for Week 2, 3, and 5 papers.
In the Week 1 paper, you will have to find three quantitative
and three qualitative research articles, for a total of six articles.
Week 2 - You will write a Qualitative research critique using 2
of the 3 Qualitative articles from the Week 1 Literature Review

13. Table
Week 3 - You will write a Quantitative research critique using 2
or the 3 Qualitative articles from the Week 1 Literature Review
Table
Week 5 - You will provide a comprehensive document,
Research Critiques, and PICOT Statement Final Draft
So, it is pertinent that you know how to tell the difference
between qualitative and quantitative research. Please review the
image below, it notes the differences between the two methods.
When conducting your search, first begin by reading the
Abstract, esp the Methods and Results. If it a Qualitative study,
then it will state either interviews or direct observations, textual
or visual analysis (eg from books or videos) and interviews
(individual or group). However, the most common methods
used, particularly in healthcare research, are interviews and
focus groups. Qualitative data is recorded and transcribed.
Qualitative data analysis involves review of transcribed data to
identify common themes.
If it is Quantitative design, instruments, surveys, or tools are
used to collect data, typically using a scale such a Likert.
Quantitative data is analyzed statistically often using SPSS
software
Literature Evaluation Table
Student Name: Student Example
Summary of Clinical Issue (200-250 words): Central line
associated infections can happen in the ICU setting and can lead
to poor patient outcomes, longer complicated hospital stays, and
increased cost in hospital stays. Education is a crucial way to
inform frontline staff about how to prevent these infections. The
creation of a bundle of ways for nurses to care for central lines
and incorporating it into their protocols and daily routine can

14. decrease the rate of infections. As a nurse in the ICU, it is
helpful for staff to have direct and clear instructions to make
sure their responsibilities and skills are being performed
according to best practice and per protocol per facility. Nurses
are at the bedside and are frequently interacting with central
lines on a daily basis in the ICU. Making simple changes such
as proper hand hygiene before and after use of a central line can
have a very positive result on the rate of the infection. The Joint
Commission has included central line-associated bloodstream
infections (CLABSIs) in their National Patient Safety Goals. It
is a problem that can cause critical issues for patients and event
result in death. Nurses can have an impact on reducing
CLABSIs by implementing evidence-based interventions, such
as hand hygiene, proper education on central line care, visual
reminders for staff in unit with key points, proper catheter
access protocol, disinfecting caps, dressing changes, and
frequent assessment of the continued need for the central line.
As a nurse in the ICU, I want to establish a central line care
bundle using evidence-based research that can reduce CLABSIs
and improve patient outcomes.
PICOT Question: Does the implementation and use of a central
line care bundle compared to a non-standardized routine reduce
the rate of central line blood stream infections (CLABSIs) in
adult ICU patients during their hospital stay?
In _______(P), what is the effect of _______(I) on ______(O)
compared with _______(C) within ________ (T)?
In Adult Intensive Care Unit patients, what is the effect of
central line care bundle on central line blood stream infections
(CLABSIs) compared with non-standardized routine care during
the hospital stay.
Criteria
Article 1
Article 2

15. Article 3
APA-Formatted Article Citation with Permalink
Scheck McAlearney, A., & Hefner, J. L. (2014). Facilitating
central line-associated bloodstream infection prevention: A
qualitative study comparing perspectives of infection control
professionals and frontline staff. American Journal of Infection
Control, 42(10), S216–S222. doi:
https://doi.org/10.1016/j.ajic.2014.04.006
Scheck, M. A. A., Hefner, J. L., Robbins, J., Harrison, M. I., &
Garman, A. (2015). Preventing central line-associated
bloodstream infections: a qualitative study of management
practices. Infection Control Hospital Epidemiology, 36(5), 557–
563. doi: 10.1017/ice.2015.27
Damschroder, L. J., Banaszak-Holl, J., Kowalski, C. P., Forman,
J., Saint, S., & Krein, S. L. (2009). The role of the "champion"
in infection prevention: results from a multisite qualitative
study. BMJ Quality and Safety, 18(6). doi:
http://dx.doi.org/10.1136/qshc.2009.034199
How Does the Article Relate to the PICOT Question?
Reiterates how frontline staff are responsible for delivering
direct and ongoing care for central lines. It helps discuss the
different perspectives about challenges of central-line
associated bloodstream infection prevention program successes.
It discusses how management and hospital-level differences can
affect the outcome of patients who have central line-associated
bloodstream infections. It gives me more of an idea of how my
hospital performs due to their level of performing. I can
recognize these barriers to help implement change to reduce
infection rates.
It explores types and numbers of champions who lead efforts to
implement best practices to prevent infections. It gives me ideas

16. on how to implement practices to prevent CLABSIs and the
characteristics is takes to promote change and improve patient
outcomes.
Quantitative, Qualitative (How do you know?)
Correct Qualitative- it describes quality and characteristics of
frontline staff through observation and interviews
Correct Qualitative- it interviews people and receives their
nonnumeric data through descriptive characteristics.
Correct Qualitative- it gathers data about characteristics of
people and observes behaviors not numeric type of data.
Purpose Statement
Infection control professionals play a critical role in
implementing and managing healthcare-associated infection
reduction interventions, whereas frontline staff are responsible
for delivering direct and ongoing patient care.
To identify factors that may explain hospital-level differences
in outcomes of programs to prevent central line-associated
bloodstream infections.
Although 20% or more of healthcare-associated infections can
be prevented, many hospitals have not implemented practices
known to reduce infections. We explored the types and numbers
of champions who lead efforts to implement best practices to
prevent hospital-acquired infection in US hospitals.
Research Question
To determine if ICPs and frontline staff have different
perspectives about the facilitators and challenges of central-line
associated bloodstream infection prevention program success.
How can management practices reflect CLABSI rates and what
can be implemented to streamline the reduction rate of
CLABSIs with appropriate and effective central line care.
Observing how champions can promote and create change
regarding CLABSIs or other hospital acquired infections/
Outcome
Study shows the need to include nurses in the implementation of
infection control initiatives. Frontline staff contribute a critical
real-world perspective that may facilitate the success of patient

17. safety interventions.
A main theme that differentiated higher from lower performing
hospitals was as distinctive framing of the goal of “getting to
zero” infections. Although all sites reported this goal, at the
higher performing sites the goal was explicitly stated, widely
embraced, and aggressively pursued; in contrast, at the lower-
performing hospitals the goal was more of an aspiration and not
embraced as part of the strategy to prevent infections.
The types and numbers of champions varied with the type of
practice implemented and effectiveness of champions was
affected by the quality of organizational networks. For practices
that require significant behavioral changes, however, a coalition
of champions may be needed.
Setting
(Where did the study take place?)
8 various sites in Ohio with approval of the Institutional Review
board of Ohio State University
Eight US hospitals that had participated in the federally funded
On the CUSP-Stop BSI initiatives.
14 hospitals from all over the US were sent surveys, telephone
interviews, sit down interviews, and some on-site visits.
Sample
Across the 8 sites in the study, they interviewed 194 key
informants with different jobs and roles in the hospitals. Among
these informants were 50 frontline nurses, and 26 ICPs. They
focused on the comments from these 76 informants because
their roles in the organizations are relevant to their research
question focusing on the perspectives of ICPS and frontline
staff.
194 interviewees including administrative leaders, clinical
leaders, professional staff, and frontline physicians and nurses.
Survey responses were used to select a stratified purposive
sample of 14 hospitals for in-depth semistructured telephone
interviews. These hospitals were selected for their potential to
further our understanding of organizational barriers and
facilitators in implementing infection prevention practices.

18. Method
They conducted interviews at 8 hospitals that participated in the
Agency for Healthcare Research and Quality CLABSI
prevention initiative called {On the CUSP: Stop BSI.” They
analyzed interview data from 50 frontline nurses and 26 ICPs to
identify common themes related to program facilitators and
challenges. Interviews lasted 30-60 minutes, and the majority
were conducted with at least 2 interviewers.
Extensive qualitative case study comparing higher and lower
performing hospitals on the basis of reduction in the rate of
central line-associated bloodstream infections. In-depth
interviews were transcribed verbatim and analyzed to determine
whether emergent themes differentiated higher from lower
performing hospitals.
Qualitative analyses were conducted within a multisite,
sequential mixed methods study of infection prevention
practices in Veteran Affairs and no-Veteran Affairs hospitals in
the USA. The first phase included telephone interviews
conducted in 2005-2006 with 38 individuals at 14 purposively
selected hospitals. The second phase used findings from phase 1
to select six hospitals for site visits and interviews with another
48 individuals in 2006-2007.
Key Findings of the Study
Identified 4 facilitators of the CLABSI program success:
education, leadership, data, and consistency. We also identified
3 common challenges: lack of resources, competing priorities,
and physician resistance. However, the perspectives of ICPs and
frontline nurses differed. Whereas ICPs tended to focus on
general descriptions, frontline staff noted program specifics and
often discussed concrete examples.
Five additional management practices were nearly exclusively
present in the higher-performing hospitals: 1) top-level
commitment, 2) physician-nurse alignment, 3) systematic
education, 4) meaningful use of data, and 5) rewards and
recognition. They present these strategies for prevention of
healthcare-associated infection as a management “bundle” with

19. corresponding suggestion for implementation.
It was possible for a single well-placed champion to implement
a new technology, but more than one champion was needed
when an improvement required people to change behaviors.
Although the behavioral change itself was often more
complicated than changing technology because behavioral
changes required interprofessional coalitions working together.
Recommendations of the Researcher
Their results suggest ICPs need to take into account the
perspectives of staff nurses when implementing infection
control and broader quality improvement initiatives. Further,
the deliberate inclusion of frontline staff in the implementation
of these programs may be critical to program success.
Adding a management practice bundle may provide critical
guidance to physicians, clinical managers, and hospital leaders
as they work to prevent CLABSIs.
Merely appointing champions is ineffective; rather, successful
champions tended to be intrinsically motivated and enthusiastic
about the practices they promoted. Create enthusiasm about the
topic because champions can implement change within their
own sphere of influence.
Criteria
Article 4
Article 5
Article 6
APA-Formatted Article Citation with Permalink
Atilla, A., Doganay, Z., Kefeli Celik, H., Tomak, L., Gunal, O.,
& Kilic, S. S. (2016). Central line-associated bloodstream
infections in the intensive care unit: importance of the care
bundle. Korean Journal of Anesthesiology, 69(6), 599–603. doi:
10.4097/kjae.2016.69.6.599
Berenholtz, S. M., Lubomski, L. H., Weeks, K., & Goeschel, C.
A. (2014). Eliminating Central-Line Associated Bloodstream

20. Infections: A National Patient Safety Imperative. Infection
Control and Hospital Epidemiology, 35(1), 55–62. doi:
https://doi.org/10.1086/674384
Guerin, K., Rains, K., & Bessesen, M. (2010). Reduction in
central-line associated bloodstream infections by
implementation of a postinsertion care bundle. American
Journal of Infection Control, 38(6), 430–433. Doi:
https://doi.org/10.1016/j.ajic.2010.03.007
How Does the Article Relate to the PICOT Question?
Explains the importance and efficacy of a care bundle for
preventing central line-associated blood stream infections in the
Intensive Care Unit. Also reinforces why central lines should be
assessed daily if they are essentially needed for care.
It shows how the implementation of the “On the CUSP: Stop
BSI” program with uniform and appropriate central line care
can reduce the rate of CLABSIs.
Studied how a post insertion bundle was effective in decreasing
rates of infection. It also gives ideas of what post insertion
interventions help prevent infections for nursing care.
Quantitative, Qualitative (How do you know?)
Correct Quantitative- it evaluates numbers that result in
measurable data
Correct Quantitative- it evaluates using numbers and concludes
with measurable data
Correct Quantitative- they did measurable methods to gather
data and evaluated using numbers.
Purpose Statement
The importance and efficacy of a care bundle for preventing
central line-associated bloodstream infections and infections
complications related to placing a central venous catheter in the
patients in the intensive care unit.
Several studies demonstrating that central line-associated
bloodstream infections are preventable prompted a national

21. initiative to reduce the incidence of these infections.
Central line-associated bloodstream infections cause substantial
morbidity and incur excess costs. The use of a central line
insertion and postinsertion bundle has been shown to reduce the
incidence of CLABSI.
Research Question
What is the effect of a central line care bundle in association
with central line-associated bloodstream infections in the ICU.
How can implementing a national program help decrease the
rates of CLABSIs.
Post insertion bundles need to be consistent and uniform to be
effective.
Outcome
The catherization duration was longer and femoral access was
more frequently observed in patients with CLABSIs. CLABSI
rates decreased with use of the care bundle.
The overall mean CLABSI rate significantly decreased from
1.96 cases per 1000 catheter-days at baseline to 1.15 at 16-18
months after implementation.
During the preintervention period, there were 4415 documented
catheter-days and 25 CLABSIs, for an incidence density of 5.7
CLABSIs per 1000 catheter-days. After implementation of the
interventions, there were 2825 catheter-days and 3 CLABSIs,
for an incidence density of 1.1 per 1000 catheter-days.
Setting
(Where did the study take place?)
In a medical ICU and a surgical ICU
Adult ICU patients in a total of 44 states, the District of
Columbia, and Puerto Rico. Collectively more than 1000
hospitals and 1800 hospital units participated
DVAMC-Denver is a university-affiliated acute care teaching
hospital which includes a 10-bed medical intensive care unit
and a 13-bed surgical intensive care unit.
Sample
In total, 114 patients who had CVCs placed in a 22-bed medical
ICU and a 12-bed surgical ICU from July 2013 to June 2014

22. were enrolled.
Adult ICU patients in a total of 44 states, the District of
Columbia, and Puerto Rico. Collectively more than 1000
hospitals and 1800 hospital units participated
All ICU patients in both the medical and surgical ICU from
October 1, 2006 to September 30, 2009 with a preintervention
and a postintervention study completed.
Method
A care bundle was implemented from July 2013 to June 2014 in
a medical and surgical ICU. Data were divided into three
periods and a post intervention period. A care bundle consisting
of optimal hand hygiene, skin antisepsis with chlorhexidine
(2%) allowing the skin to dry, maximal barrier precautions for
inserting a catheter, choice of optimal insertion site, prompt
catheter removal and daily evaluation of the need for the CVC
was introduced.
They conducted a collaborative cohort study to evaluate the
impact of the national “On the CUSP: Stop BSI” program on
CLABSI rates among participating adult intensive care units.
The program goal as to achieve a unit-level mean CLABSI rate
of less than 1 case per 1000 catheter days using standardized
definitions from the National Healthcare Safety Network.
Multilevel Poisson regression modeling compared infection
rates before, during, and up to 18 months after the intervention
was implemented.
Surveillance for CLABSI was conducted by trained infection
preventionists using National Health Safety Network case
definitions and device-day measurement methods. During the
intervention period, nursing staff used a postinsertion care
bundle consisting of daily inspection of the insertion site; site
care if the dressing was wet, soiled, or had not been changed for
7 days; documentation of ongoing need for the catheter; proper
application of a chlorohexidine gluconate-impregnated sponge
at the insertion site; performance of hand hygiene before
handling the intravenous system; and application of an alcohol
scrub to the infusion hub for 15 seconds before each entry.

23. Key Findings of the Study
Infection rate increased when catheters remained in place longer
than needed, when healthcare workers did not follow the care
bundle practices, and when the catheter was placed via a
femoral route. During first 6 months, there were difficulty
complying with care bundle practices improved with regular
coordination meetings.
Coincident with the implementation of the national “On the
CUSP: Stop BSI” program was a significant and sustained
decrease in CLABSIs among a large and diverse cohort of ICUs,
demonstrating an overall 43% decrease and suggesting the
majority of ICUs in the US can achieve additional reductions in
the CLABSI rates
Findings demonstrate that implementation of a CVC
postinsertion care bundle was associated with a significant
reduction in CLABSIs. This study demonstrates that
interventions developed by front-line nursing staff can be a
highly effective response to a problem.
Recommendations of the Researcher
Use of all barrier precautions and removal of catheters when
they are no longer needed are essential to decrease the CLABSI
rate.
Have well-defined, evidence-based interventions. Build a solid
implementation structure and project plan. Collect and use
timely, accurate, and actionable data to improve performance.
Tailor national program for local and unit audiences. Evolves
project strategies and emphases over time.
Staff education and reinforcement of proper CVC care after
insertion, along with careful cleaning of the hub before access,
might reduce the incidence of infection.
7

24. Literature Evaluation Table
Student Name:
Summary of Clinical Issue (200-250 words):
PICOT Question:
Criteria
Article 1
Article 2
Article 3
APA-Formatted Article Citation with Permalink
How Does the Article Relate to the PICOT Question?
Quantitative, Qualitative (How do you know?)
Purpose Statement
Research Question
Outcome
Setting

25. (Where did the study take place?)
Sample
Method
Key Findings of the Study
Recommendations of the Researcher
Criteria
Article 4
Article 5
Article 6
APA-Formatted Article Citation with Permalink
How Does the Article Relate to the PICOT Question?
Quantitative, Qualitative (How do you know?)

26. Purpose Statement
Research Question
Outcome
Setting
(Where did the study take place?)
Sample
Method
Key Findings of the Study
Recommendations of the Researcher

27. 2
Title
ABC/123 Version X
1
Health Care Timeline
HCS/235 Version 10
1University of Phoenix Material
Health Care Timeline
Complete the following timeline.
Select seven events that have helped shape health care as it is
today. Write a 50- to 150-word summary per event that
discusses the event and its effect on the health care industry. An
example has been provided for you.
Health Care Throughout the Years
Date
Event and Significance
1870-1889
Employers began to provide employee health care. Companies
in several industries, including mining, lumber, and railroads,
developed group industrial clinics with plans that prepaid
doctors a fixed monthly fee to provide medical care to
employees for industrial accidents and common illnesses.

28. Cite your sources below. For additional information on how to
properly cite your sources, check out the Reference and Citation
Generator resource in the Center for Writing Excellence.
References
Copyright © XXXX by University of Phoenix. All rights
reserved.
Copyright © 2017 by University of Phoenix. All rights reserved.