Explaining Michigan

Developing an Ex Post Theory of a Quality Improvement Program

In order to inform future quality improvement programs, researchers need to know why certain interventions work and what to do the same—or differently—when replicating a program.

These researchers used an ex post theory to explain the success of the Michigan Intensive Care Unit (ICU) project in reducing rates of central venous catheter bloodstream infection (CVC-BSI) in more than 100 ICSUs. The program reduced infection rates to zero in three months and held that rate over 18 months by:

  • Generating isomorphic pressures for ICUs to join the program and conform to its requirements.
  • Creating a densely networked community with peer monitoring within and across hospitals that evolved into a virtual learning community.
  • Reframing CVC-BSIs as a social problem, one that could be solved by human action and behavior, addressing it through a professional movement using leaders who were ICU “insiders.”
  • Institutionalizing good practices for insertion of a CVC using a nurse-monitored checklist.
  • Sharing blinded data on infection rates motivated units to match the performance of those reporting the lowest rates.
  • Using some “hard edges” such as the checklist and sanctions for failure to report data.

Today, ICUs around the world seek to “Match Michigan.”

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