Case Study: Agency for Healthcare Research and Quality

This case study focused on the quality initiatives necessary to improve and enhance patient care. Nurses General Nursing Article

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  • Specializes in Emergency Service and Critical Care.
Case Study: Agency for Healthcare Research and Quality

The focus of this case study was very interesting. ChristianaCare used three different quality initiatives to improve and enhance patient care.

  1. ChristianaCare identified nursing staff felt that with the insertion of a catheter device there was a significant risk of a patient developing a bloodstream infection.
  2. They also were concerned about the length of time it took a stroke patient to receive surgical intervention.
  3. Lastly, they felt that patient safety was should be a top concern within their organization.

ChristianaCare adopted the Agency for Healthcare Research and Quality (AHRQ) tools. The Comprehensive Unit-Based Safety Program (CUSP), TeamSTEPPS, and Surveys on Patient Safety Culture (SOPS) to improve the care of their patients. These are evidence-based resources that reduced catheter infections and cut the time to surgical intervention in half (AHRQ, 2020). The SOPS surveys provided staff and physicians with information about the culture of safety and promoted strategies within the organization.

Identifying Data

ChristianaCare saw a reduction in bloodstream infections due to the strategies of CUSP. The goal of CUSP is to emphasize the safety culture by reporting and learning from errors. It promotes working as a team and supporting and engaging staff (Pitts, et al., 2017). In the ICU they decreased from 21 cases in 2011 to four cases in 2019 (AHRQ, 2020). This reduction reduced the catheter days from 12,627 to 6,574 days in 2019 (AHRQ, 2020). The nurse became engaged and aware of the interventions the CUSP tool provided.

The TeamSTEPPS was initiated and expedited the stroke patient care through improved staff communication. Using the TeamSTEPPS tool resulted in faster care and treatment of the stroke patient. The time was cut in half. Utilization of this tool encouraged teamwork and clear communication among staff and improved patient care.

Patient safety is the utmost important factor in healthcare. The SOPS survey allows staff to remember the importance of patient safety and the survey allows staff to share their perception. The SOPS survey is conducted every two years. The survey provides an organization with internal information that can provide insight.

Contrast Outcomes of the Study

The AHRQ, Joint Commission, and the National Quality Forum are just some examples of regulatory agencies that require patient safety to be collected and reported. Hospital organizations held to higher standards are expected to meet these standards. Process changes are initiated based on the findings that are discovered during data collecting and data sharing (Hughes, 2008). Industry standards hold hospitals accountable.

Evaluate and Implementation of a New Practice

ChristianaCare implemented evidence-based tools and resources that will provide safe and quality care. Providing quality and safe care should be the goal for all hospital organizations. Communication tools have been proven to promote patient safety. Employee engagement in process change is essential. These tools can allow staff to become self-driven and responsive. Implementing new practices within an organization can be a challenge but if rolled out properly it can be very successful and sustainable.


In today’s society patients are smart consumers. Patients can pick where they want to go for medical care. They can use social media to inform other patients about their care or lack of care. Healthcare organizations need to be providing quality and safe care. The culture has changed in healthcare and hospitals are responsible for collecting and sharing data to ensure patients that they are receiving the best care possible.  


ChistianaCare Used AHRQ Resources to Reduce Blood Infections, Expedite Stroke Care. (2020) Agency for Healthcare Research and Quality, Rockville, MD.

Hughes, R.G. (2008). Tools and strategies for quality improvement and patient safety. Patient Safety and Quality: An Evidenced-Based Handbook for Nurses. Rockville, MD.

King, H.B., Battles, J., Baker, D.P., Alonso, A., Salas, E., Webster, J., Tooney, L., Salisbury, M. (2008). TeamSTEPPS: Team strategies and tools to enhance performance and patient safety. Advance in Patient Safety: New Directions and Alternatives. 3(1), 1-19.

Pitts, S. I., Maruthur, N. M., Luu, N. P., Curreri, K., Grimes, R., Nigrin, C., Sateia, H. F., Sawyer, M. D., Pronovost, P. J., Clark, J. M., & Peairs, K. S. (2017). Implementing the Comprehensive Unit-Based Safety Program (CUSP) to Improve Patient Safety in an Academic Primary Care Practice. Joint Commission journal on quality and patient safety, 43(11), 591–597.

Tammy Leigh has 35 years experience and specializes in Emergency Service and Critical Care.

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