This document summarizes a hospital's SWOT analysis and action planning to reduce catheter-associated urinary tract infections (CAUTIs). It identifies strengths like supportive leadership and daily monitoring of catheter needs, as well as weaknesses such as lack of education and standardized protocols. Potential solutions are discussed, such as revising order forms, developing bundles and checklists, and improving physician accountability. An action plan is created with assigned responsibilities, timelines and metrics to track progress in reducing CAUTIs over time.

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CAUTI Reduction Team
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CAUTI Reduction
SWOT Analysis
Team Review
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CAUTI Reduction SWOT Analysis
Strengths
 Only place caths when
necessary (i.e. narcotic spinals,
intubated ICU patients, TURPs)
 Daily foley rounds (Leadership
and Infection Prevention)
 Preprinted Surgical Post-op
orders specific to Foley
discontinuation day
 Physicians are very receptive
to the implementation of
renewing Foley orders every 24
hours and removing Foley as
soon as they are no longer
medically necessary.
 CEO is SUPER supportive.
 Monday-Friday morning huddle
includes discussing every
patient that has a Foley and
assessing if the Foley is still
needed.
 Hospitalists agreeable to get
Foleys out ASAP
 Enthusiasm from Quality
 Leadership engagement
 Less insertion in ED already in
place
 Criteria for insertion posted in
ICU
 Everyone here today! 3

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CAUTI Reduction SWOT Analysis
Weaknesses
 Sterile technique
 New residents placing Foleys
on patients when they’ve never
been educated on how
 Broken/lack of sterile technique
 No nurse driven discontinuation
protocol
 No pre-printed Foley orders for
non-surgical admissions
 Lack of physician champion.
 Some “old school” physicians
are not as interested in
changing their catheter use.
 Nurses feel it is safer to put a
Foley in than leave a patient in
a wet brief due to the shortage
of staffing and not being able to
get to the patient in a timely
manner.
 Lack of education for everyone
 Documentation on bag
 No foley review by quality on
Saturday and Sunday
 Poor documentation when foley
discontinued
 Staff not aware of criteria for
insertion
 Staffing when foley is for
convenience 4

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CAUTI Reduction SWOT Analysis
Opportunities
 Sterile technique refresher – Foley
insertion practice station
 Education on why removal ASAP is
so important
 Insert less catheters in the ED
 Catheters discontinued at the end
of surgery instead of the next day.
 Unit champions
 Nurse driven protocols
 Improve documentation for
catheter care
 Education on proper cath size
 Evidence based practices for labor
epidurals
 Competency checklists
 Correct supplies available to staff
when inserting a Foley.
 Not break drainage system to
change catheter size.
 Securement devices used on all
Foleys
 Keep collection bag below the
bladder to prevent backflow.
 Increase # and availability of
bladder scanners
 Consistent charting of initiation
date and time
 Review with bedside nurses foley
placement on patient
 Evaluate and standardize supplies
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CAUTI Reduction SWOT Analysis
Threats
 Physician and staff education –
when to insert, how to insert,
when to remove
 Lack of support from Urology
staff
 Keeping supplies filled
 Adequate staffing so nurses
are not rushed while
performing catheter insertion
 Staff no accepting change
 Nurses too busy to participate
in successful implementation.
 MDs and RNs taking short cuts
with sterile technique
 Lots of new nurses and new
grads
 Catheter occasionally inserted
prior to obtaining order
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Trace your process to visualize what
really happens!
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• System-level tracer questions
• Patient-level tracer questions
•Interview staff
•Review patient records
•Talk to patient and family if
possible

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Tracer Findings
Good
 Physicians aware of “Foley
Nazi”
 Awareness of foley need and
need for CAUTI reduction
 Starting to use checklist for
order
 Decrease use in OR
Inconsistent
 Dependent loops
 Bag higher than foley
 No stabilizer
 Communication with patient not
appropriate or adequate
 Documentation of insertion,
maintenance, DC
 Breaks in technique
 Use for nurse convenience,
criteria inappropriate
 Assistance use to maintain
sterile field
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Process Mapping

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Process Map of Current State
with Risk Points

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Gallery Walk Instructions
Purpose: To Create the Cause and Effect Diagram
1. Assemble a few people at each flip chart
2. 2 minutes at each chart until you get to your originating chart (consultant is timing
and will instruct you to move to the next chart).
3. Silently write one factor per post it note and write as many factors related to the
topic in 2 minutes as you can. Try to state the factor in neutral terms (for
example, rather than say physicians “lack of knowledge about ABC”, say
“Physicians’ knowledge about ABC”)
4. Move to the next flip chart when the facilitator tells you to and read the Post it
notes already there. Do not repeat
5. When you return to your original flip chart, group can talk and arrange post it
notes into common themes and then name each group (what is the theme?)
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Gallery Walk
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CAUTI Reduction Cause &
Effect Diagram
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Solution Generation
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Potential Solutions Votes
Revise and consistently implement Foley order form, including
definition for "strict I&O" 4
Develop standardized bundles and checklist 3
Improve physician accountability and responsiveness 2
Revise policy - evidence based and available 1
Work with Vendor to evaluate supplies and develop criteria for
us of urometer 1
Define and implement competencies 1
Develop and implement nurse driven foley catheter removal
protocols 1
Improve nurse accountability, especially in relation to
incontinence 1
Scripting responses as part of rounding in relation to toileting 0
Implement bladder scanners on each unit 0
Unit based champions 0
Provide unit specific rates 0
Build alerts in Omnicell for medications that may cause
retention 0

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Writing a 3 W Workplan
 When writing the action plans each ‘what’ should start with a verb, such
as “Collate all forms currently used to teach heart failure to the patient.”
 The ‘who’ can be anyone on the team, not just the subgroup working on
the particular issue. This is the name of person on this performance
improvement team who will be responsible for seeing that this action item
gets completed. The assigned “who” does not necessarily DO all the
work associated with the action item, rather – they assure that it is done
and may participate in the work too.
 Allow time for each subgroup to present to each other, for any additional
tips, editing, points of clarification etc. Good practice prior to leadership
presentation too.
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CAUTI Reduction Deployment–
3W Plan
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WHAT WHO WHEN
Revise and consistently implement Foley order
form, define “strict I&O”
Heather/Debra Sept. 30
Standardize bundles and implement checklist Educator/
Project List
Jan. 1
Improve physician accountability and
responsiveness
-Use ARCC
-Define chain of command for Foleys
Dr. Mehta Sept. 30

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CAUTI Reduction Deployment–
3W Plan
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WHAT WHO WHEN
Use vendor to evaluate supplies and develop
criteria for urometer use
Becky/Sheila Sept. 30
Define and implement competencies Educator TBD
Develop and implement nurse driven foley
catheter removal protocols
Anabelle/
Susan
Jan. 1
Improve nurse accountability
-removal
-incontinence management
Nursing
Directors
Sept. 1
Revise policy Cynthia/Becky Ongoing

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Deployment Planning
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Outcome Metric
 CAUTI for ICU patients
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Possible Leading metrics
(Process metrics)
 Urinary catheter removed post op day 1 or 2
 Time delay of removal identification and removal
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Parking Lot
 Monitoring of Intake and Output
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CAUTI Reduction
Plus/Delta Evaluation
PLUS
 Gallery walk – great way to
generate ideas
 Allowing free and safe
conversation
 Great presentation to C-Suite
 Very interactive – action taken
towards goal
 Great start for the leadership
 Learning lots of new techniques
 Great techniques to use with
other projects and department
meeting issues
DELTA
 None
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Summary
 The PfP Campaign is a national, high-priority effort to
prevent harm to inpatients
 The JCR HEN is prepared to assist you achieve the
“40/20 by ’14” goal
 Your PfP project infrastructure will serve as a
foundation for strong PI work
 You will be successful and your results will be
sustainable!
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