40 ISE Magazine | www.iise.org/ISEmagazine
Is improvement methodology limited to only hard dol-
lar savings? Can methodologies such as Lean, Six Sigma
or ISO 9001:2015 save lives if leveraged properly? Is
waste the only application for improvement or are other
viable targets warranted? Is improvement only a pipe
dream or can it become a reality with the right struc-
ture, process and people focus? Can change agents realize
long-term improvement wins that stand the test of time even
in the face of a pandemic or is sustainability a mirage that
quickly fades with time?
We will answer these and other considerations in this article.
Several years ago, Atrium Health Navicent began a jour-
ney to achieve higher performance. The provider has more
than 1,000 beds for medical, surgical, rehabilitation and hos-
pice purposes, offers over 53 specialties in more than 50 facil-
ities throughout the region and hosts more than 100 medical
residents and fellows. Included within the system is Atrium
Health Navicent The Medical Center, a 637 bed, nationally
verified Level I-designated trauma center and a three-time
Magnet designated hospital for nursing excellence world-
The journey focused on this flagship hospital for the health
Leveraging improvement efforts to reduce
hospital infections
Certification process led to strategies that improved patient outcomes
By Sonya Floyd and Casey Bedgood
September 2022 | ISE Magazine 41
system. The first step was to adopt methodologies such as
Lean and Six Sigma. Once hundreds of internal stakeholders
were trained, deployment occurred with the aim of improv-
ing the value equation, which at its core consists of service,
cost and quality.
The goal is to maximize the value provided to every cus-
tomer. This may be achieved by providing enhanced ser-
vices at lower costs with better health outcomes. Tactically,
improvement methodologies were used to address oppor-
tunities beyond the traditional process-related waste. Some
initiatives included the redesign of structure to accompany
process improvements and the like.
Once the basics were in place, the hospital pursued ISO
9001:2015 certification and successfully passed the exam. In
2017, The Medical Center received this coveted designation
and began to elevate outcomes with an aggressive improve-
ment focus. The team focused heavily on the core elements
of ISO 9001:2015 as the catalyst for next level performance.
These core elements include, but are not limited to, attri-
butes such as a laser focus on customer requirements, involv-
ing top leadership in all improvement activities, leveraging
data to make evidence-based decisions, improving every-
thing, managing relationships for better outcomes and maxi-
mizing organizational knowledge.
The team began this journey by identifying top senior
leaders as ISO 9001:2015 ISO champions. Each year, these
leaders received various training and signed contracts out-
lining their obligations to the improvement journey. These
sponsors led the journey to ensure tollgates were reached and
that the organization matured with methodology.
The team also leveraged data to better inform stakeholders
of the current operating environment including perceived
and actual risks, hot spots that needed immediate attention
and segmenting real improvements from perceived improve-
ments. The goal was to remove thought, feeling or emotion
from organizational decision-making, thus allowing objec-
tive data to lead the way forward, prevent leaders from act-
ing when unnecessary and reacting appropriately when the
circumstances aligned.
Also, the team redened the term “customer.” Tradition-
ally in healthcare, the customer has always been the patient.
But in today’s world, is a patient the only customer? Are staff
and leaders also customers? Are vendors and contractors who
provide goods and services customers? Should government
agencies, regulatory entities and the like also be added to the
stakeholder list? The short answer is that “customer” applies
to all the above and more. Anyone who touches an organi-
zation directly or indirectly is essentially a customer. Thus,
renement of the customer concept was crucial in dening
the improvement journey.
Finally, the team shifted focus and leaders invested count-
less time, effort and resources to capturing organizational
knowledge. In simplest terms, the hospital increased its docu-
mented policies, work instructions and the like by over 50%.
These guides for completing work were stored real time in a
knowledge management system accessible to all stakeholders
when needed and standardized with templates. The goal was
to create a culture of standard work, standardizing processes
and the way work is done.
Identifying improvement targets
Once the basics were in place and aligned with organization-
al culture, the team began to identify granular opportuni-
ties that would greatly improve the value equation for thou-
sands of customers annually. Two focus areas were hospital
infections such as C. diff (Clostridioides difcile) and CAUTI
(catheter-associated urinary tract infections). The key is that
any infections are bad. The goal is for hospitals to avoid in-
fections, proactively prevent them from becoming worse, if
present, and eliminate these risks with proactive action plans.
Let’s dene these target infections along the improvement
journey. The Centers for Disease Control and Prevention
(CDC) denes C. diff as “a germ (bacterium) that causes se-
vere diarrhea and colitis, an inammation of the colon. Most
cases of C. diff infection occur while youre taking antibiot-
ics or not long after youve finished taking antibiotics.” This
can be life-threatening if not treated properly, and preven-
tion, early detection and proper treatment are key for success.
The other infection targeted was CAUTI, which the CDC
denes as a urinary tract infection (UTI) “involving any part
of the urinary system, including urethra, bladder, ureters and
kidney. UTIs are the most common type of healthcare-asso-
ciated infection reported to the National Healthcare Safety
Share your healthcare solutions
at HSPI 2023
Do you have a healthcare systems improvement story or re-
search to share? Presentations are now being sought for the
Healthcare Systems Process Improvement Conference, Feb.
15-17, 2023, at the Kentucky International Convention Center
in Louisville, Kentucky.
Abstract submissions are due by Sept. 30. Learn more at
link.iise.org/hspi2023-abstracts and look for upcoming infor-
mation on speakers and program information at iise.org/HSPI.
42 ISE Magazine | www.iise.org/ISEmagazine
Leveraging improvement efforts to reduce hospital infections
Network (NHSN). Among UTIs acquired in the hospital,
approximately 75% are associated with a urinary catheter,
which is a tube inserted into the bladder through the urethra
to drain urine. Between 15%-25% of hospitalized patients
receive urinary catheters during their hospital stay. The most
important risk factor for developing a catheter-associated
UTI is prolonged use of the urinary catheter. Therefore,
catheters should only be used for appropriate indications and
should be removed as soon as they are no longer needed.
The team realized that both infection rates were higher
than acceptable in this facility. A two-pronged approach was
pursued to lower both infection types. For C. diff, the team
focused heavily on early detection with testing. If infections
were identified, then treatment protocols were implemented
to mitigate the risk and seek to end the infection sooner.
Other techniques such as enhanced hand hygiene also
were implemented. This is a basic fundamental, but impor-
tant in addressing infections. Other cleaning procedures for
equipment and physical environment space were updated
and reinforced.
Data reviews also became part of the operational canvas.
These helped leaders and other stakeholders identify high
risk patients and create better decision trees to prevent or
mitigate risks associated with these infection subgroups. Fi-
nally, treatment protocols such as isolation were leveraged as
Similarly, the team implemented several tactics to combat
CAUTI. For example, protocols were updated, standard-
ized, cascaded to stakeholders and reviewed periodically to
ensure effectiveness of care and services. Also, upskilling was
a major part of the improvement prescription. Techniques
such as utilizing skills days, orientation, competencies and
other training for clinicians were successful. With enhanced
knowledge, care was better.
Also, the team leveraged an evidence-based decision ap-
proach. Here, leaders established goals, measured data and
included this insight into regular report-outs to teams, lead-
ers and other stakeholders. The key was situational aware-
ness. The goal was to ensure that stakeholders knew when
action was needed versus when it was not.
New techniques were also injected into the improvement
equation. For example, a new noninvasive device was used,
when applicable. The team learned that limiting the occur-
rences of introducing a foreign body (i.e., catheter) into the
patients helped reduce infection rates.
After implementing these tactics, periodic reviews were
conducted to measure the effectiveness of all solutions. If
they were found to be effective, the team continued full
steam ahead. If solutions proved to add no value, the team
would pivot until the optimal improvement was identied.
This ties directly back to evidence-based decision-making,
relationship management and continuous improvement in
ISO 9001:2015 methodology.
Measuring outcomes
The team realized significant improvement outcomes as it
relates to both infection groups. For both C. diff and CAU-
TI infections, the team studied progress over approximately
a 10-year period. The data set included monthly infection
counts per subgroup from 2013 to 2022. As noted, the hos-
pital became ISO 9001:2015 certified in 2017. Thus, several
years of data before and after certification was included in
the review.
The team realized a 50% reduction on average in C. diff
infections (see Figure 1 for details). The null hypothesis
states there was no change. The alternative hypothesis states
that C. diff rates were reduced post ISO 9001:2015 certifica-
tion. Test of hypothesis (paired comparison large sample size)
C.diff count
The team realized a 50% reduction on average in C. diff infections.
September 2022 | ISE Magazine 43
was utilized to test the theory. In short, the 50% reduction
in C. diff infections was significant at the 99% condence
level as Z test (6.75) was greater than 1 Tail Z Table (2.32).
Thus, infections improved post-ISO 9001:2015 certification
at this facility.
The hospital also realized a 16% reduction in C. diff stan-
dard deviation (Figure 2). The takeaway is that both the
number of infections and the variation in these outcomes
were significantly improved post-ISO 9001:2015 certifica-
Next, the team tested the CAUTI outcomes. As noted in
Figure 3, there was a 53% reduction in CAUTI infections
following ISO 9001:2015 certification. The null hypothesis
states there was no change. The alternative hypothesis states
that CAUTI infections declined. Test of hypothesis (paired
comparison large sample size) was used to test the theory. In
short, the 53% reduction in CAUTI infections was signi-
cant at the 99% condence level as Z test (3.19) was greater
than 1 Tail Z Table (2.32). Thus, infections improved post-
ISO 9001:2015 certification at this facility.
C.diff box plot
The hospital realized a 16% reduction in C. diff standard deviation after ISO 9001:2015 certification.
CAUTI count
The team found a 53% reduction in CAUTI infections post-certification.
44 ISE Magazine | www.iise.org/ISEmagazine
Leveraging improvement efforts to reduce hospital infections
As with C. diff variation, the facility realized a 50% re-
duction in CAUTI standard variation (see Figure 4). The
takeaway is that both the number of CAUTI and the varia-
tion in these outcomes were significantly improved post-ISO
9001:2015 certication.
Lessons learned
In retrospect, there are several lessons the team learned
along the journey. One, leaders and their organizations dont
know what they dont know. Ignorance is never bliss. The
key is measurement. The old adage of “measure twice and
cut once” applies here. What leaders dont measure and sub-
sequently dont know will eventually unfavorably impact
them, their organizations and the customer.
Two, all good improvement starts with a methodology.
Regardless of their flavor, Lean, Six Sigma or ISO 9001:2015
really work if the basics are in place. Success depends upon
top leadership sponsorship, evidence-based decision-mak-
ing, organizational knowledge and a clear vision for what
success really is. If the key attributes are in place, the meth-
odology will succeed.
Three, organizations must dene the customer and un-
derstand what value means to each one. The customer or
stakeholder list should be exhaustive and span beyond the
traditional view of “patient,” as in the healthcare example.
Once primary and secondary customers are identified,
change agents should ensure these attributes are represented,
measured, tracked and improved so value is enhanced to all
In summary, improvement methodology should not be
limited to only hard dollar savings. Improvements tied to
direct customer outcomes in service and quality are equally
if not more important in certain scenarios. Also, methodolo-
gies such as Lean, Six Sigma or ISO 9001:2015 can and do
save lives if leveraged properly. The key is having change
aligned with organizational culture and customer require-
Moreover, improvement can be a reality, not just a pipe
dream with the right structure, process and people focus.
Finally, change agents can realize long-term improvement
wins that stand the test of time even in the face of a pan-
The takeaway is that insight, knowledge and methodology
are impactful. Effective leaders are those who understand the
customer, leverage evidence to make life-saving decisions,
measure and mitigate risk and sustain wins long term.
Authors’ note: The team would like to give a special thanks to
Quality, Accreditation, Lab, leadership and the staff that relentlessly
provide great care and services to tens of thousands of patients each
year. This is a testament to the teams commitment to providing the
safest, highest quality of care possible.
Sonya Floyd RN, BSN, CIC, is Infection Prevention Control and
Epidemiology System Manager for Atrium Health Navicent.
Casey Bedgood, MPA, CSSBB, is a Six Sigma Black Belt (IISE)
and System Accreditation Optimization Ofcer for Atrium Health
Navicent. He is an IISE member.
CAUTI box plot
As with C. diff variation, the facility realized a 50% reduction in CAUTI standard variation.