You do not have zero healthcare associated infections (HAI) – at least not in the long run. Everyone makes mistakes, employees do not do what they are supposed to, and in the end you are hurting the very people that you are there to help. It can feel like an impossible problem. You can’t seem to get the right information to the right people and more importantly you can’t get them to do the right thing. The result are HAIs which leads to lower staff satisfaction, patient satisfaction, and increased costs to the system. While zero infections may not be an achievable goal, you can increase the time between infections.

We help organizations create and leverage the bundles, supporting practices, and environments necessary to change HAIs from an everyday occurrence to the exception. Our proven track record of creating short term and long term improvement in HAI rates shows that while you may not be able to completely prevent HAIs, you can substantially reduce them.


Everyone has practices. Some of them are even best practices. Some of them are evidence based bundles. Even with evidence based bundles it’s hard to get everyone to do the right thing all the time – or even most of the time. Getting practice right – and agreed upon – is difficult but not impossible.

Starting with evidence based bundles creates a common discussion for all of the care providers and allows for standardization of practice around proven approaches. Once the bundles are established it’s gaining acceptance of them and the development of the supporting practices that makes them work.

Using the model of the body, the evidence based bundles are the bones which provide the structure for care. However, it’s the supporting practices – the practices that support the bundle – that makes the bundle work – like the muscles of our body.

Developing these supporting practices means bringing new knowledge to all of the players – in a way that’s both effective in terms of time and costs but also is effective in terms of the retention of the knowledge. By providing both educational resources and performance support (job aids), all care providers are able to provide the best possible care – at all times. While professional expertise is needed in some cases, with standard practices the number of consultations will go down at the same time quality of care is going up.


Learning from History

HAIs are considered harm events for your patients. Somewhere there was something or multiple things that led to the patient being harmed. Learning from each HAI individually and collectively and identifying associated actions or events can turn a harm event into a change that protects all your future patients. There are two methods that we learn from harm events.

The Apparent Cause Analysis (ACA)

The first method of learning from harm events is an apparent cause analysis (ACA) of the individual event. This is the deep dive into everything associated with the patient and specifically around the associated device for the 96 hours prior to the event. It requires conversations with the staff and even discussions with the patient and/or their family. It includes a thorough review of the patient’s chart to find any unexpected events or potential areas of harm. The concluding event of an ACA includes a “huddle” of all staff involved in the care of the patient to identify opportunities for harm and to more importantly identify opportunities to prevent harm in the future.

The purpose of ACA is to identify the potential causes for the infection and work towards preventing barriers to future infections based on the same vectors. This could be updating a procedure, changing a product, or as simple as providing additional education. The military has used after action reviews (AARs) for years to help them improve their operations and learn from mistakes. ACAs are in effect AARs with the added benefit of a lead investigator who knows what sorts of problems lead to infections.

The Systematic Cause Analysis (SCA)

The second method of learning from harm events includes a systematic cause analysis (SCA). This is the evaluation of the results of all the ACAs in a facility to find trends and similarities. The SCA can provide insight into opportunities to change practice that better protect your patients based on the experiences in your own facility.

SCA identifies unidentifiable patterns by looking at infections that are clustered around a department, procedure, or product. By identifying the common denominator it’s possible to eliminate or reduce a whole group of infections by resolving the systemic problem that was leading to the infections. These systemic causes aren’t always apparent during the Apparent Cause Analysis. They only become apparent when multiple infections are evaluated together.


Basho (Ba) is a Japanese term that translates into a shared space (physical, virtual, or conceptual); this shared space is a foundation for knowledge creation and shared understanding. Basho develops through inter-individual relationships, that develop into a collective relationship. This collective relationship supports practices, values, processes, culture, and climate in a more or less formalized way. The energy developed through shared creation supports internalization of knowledge and catalyzes reflection, this transforms knowledge into action. When different views of the same problem combine in an environment that focuses on the common good, these views bring a new awareness and response to problems and practice. In healthcare there are many different views, each with direct impact on the patient. Combining these views with an ideology of shared space changes the interactions of all staff. Every individual is considered important for the greater good and part of ultimate solution to providing the best outcomes.

Frequently education is the first response to a problem, rarely is education the primary solution. The need for education must be assessed. It must be recognized that the transformation of knowledge into action is the ultimate goal. Basho supports continued knowledge creation and shared vision. This continuous transformation of knowledge into action supports the team in consistently providing what is most important to the patient, safe and effective care.

Everett Rogers in his book, The Diffusion of Innovations, speaks about how people learn and more importantly change their behaviors. The model Rogers uses is the Knowledge-Attitudes-Practices model. In this model, knowledge doesn’t necessarily change behavior. While knowledge can come from even mass-media sources, it’s level of impact is limited. Attitudes are changed when someone who I trust makes a change. There are some early adopters that don’t need peers to have tried the innovation but the rest of the curve that Rogers created needs a close personal connection to someone who has already “blazed the trail.” The final level of the model is the changing of practices and is a personal decision to make a change. This personal decision can be easy because of sufficient external support or can be difficult because of the lack of support.

In our experience with Basho we create not just the knowledge that is necessary to better care for patients but we change the attitude and ultimately the practices by building a community around the evidence based practices that lead to results. By creating a space where everyone can come together and experience what it’s like to have everyone working towards zero infections, a Basho is created.

Once the environment is created and the values are shared, the Basho operates like a continuous improvement engine. It helps people come together in a way that facilitates the shared understanding and true dialogue that leads to incremental improvements over time. Continuous quality improvement may have been started by Edwards Deming in manufacturing, but with Basho it can become a reality in healthcare.