Sample Leadership Paper on Reducing Catheter-Associated Urinary Tract Infection

Globally, hospitals are under pressure to improve the quality of care while maintaining a high level of efficiency and cutting costs. Healthcare organizations must continually improve their processes by incorporating best practices and implementing sound policies throughout the system to achieve this. This paper addresses a quality improvement issue related to my current place of work, Veterans Hospital. The QI project aims at suppressing the number of catheter-associated urinary tract infections (CAUTI) in the hospital. When compared to their counterparts, patients with CAUTI experience increased length of stay (LOS) in hospitals. Prolonged LOS due to CAUTI can lead to downstream complications, such as urosepsis, pyelonephritis, or even death. Similarly, increased LOS leads to an increased cost of care, which is not desirable to patients. In the United States, it is estimated that 449,000 cases of CAUTI occur each year, costing more than $450 million annually. With CAUTI accounting for more than 32% of all hospital-acquired infections, implementing a quality improvement project that can tackle the issue is necessary for our hospital.

The Quality Improvement Issue: Policy and Processes

Quality improvement (QI) entails a series of continuous and systematic actions that result in measurable improvements in the health status of the targeted patient population and health services. In healthcare, quality is a direct correlation between the desired health outcomes and improved health services. Healthcare-associated infections (HAI) lead to a high cost of healthcare and increased cases of mortality and morbidity.  According to Theobald, Resnick, Spain, Dittus, & Roumie (2017), CAUTIs are the most common forms of HAI, accounting for more than 1 million cases in Europe and the U.S. annually. The infections also account for up to 13,000 deaths annually (Wright, 2019). A quality improvement project proposes using an intervention toolkit that focuses on CAUTI detection and prevention strategies to deal with the problem of CAUTI in our Veterans Hospital. The team seeks to implement an algorithm-based urinary catheter (Foley) assessment tool able to indicate catheter discountenance among the patients. The Foley assessment tool would be built in the hospitals electronic medical records (EMR)

Policy Aspect of the Issue

As a policy measure, the implementation of the CAUTI Surveillance Bundle and Urinary Catheter assessment tool seeks to advance a hospital-wide policy of CAUTI presentation strategies. The hospital wants to adopt a policy that promotes zero hospital-associated infections, with CAUTI being the major focus. A key step towards achieving this strategic goal is to ensure that all clinical staff, especially nurses, can assess and implement catheter discontinuance protocols to avoid over-use (Davis et al., 2014). Similarly, educating and creating awareness on the side of all stakeholders, especially the patients and nursing staff, on the use of the algorithm-based Foley assessment tool will ensure that infections are detected early, and corrective actions are taken. The Foley assessment tool will ensure that the hospital transforms towards a policy of promoting patient safety, which is key to improving patient outcomes.


The hospital is keen on implementing hospital-wide practices that aim at reducing CAUTI cases at the facility. The QI initiative recognizes the role played by the nursing staff in implementing care standards. Appropriately assessing the need for catheterization, insertion, and subsequent removal, as well as catheter maintenance, is key to reducing CAUTI in the hospital (Bell, Alaestante, & Finch, 2016). Since the assessment tool will be built in the hospital, the staff will first complete a mandatory electronic education module that will educate the staff on how to use the Foley assessment toolkit. Further, the nursing staff will be taught how to fill the assessment checklist daily as part of the catheter monitoring process.

Evaluation of the Current State of the Organization as it Relates to the QI Issue

As a veterans’ hospital, most of the patients who visit the facility are adults, with some having underlying medical conditions. The hospital’s mission is to maintain high levels of safety and patient satisfaction by reducing the length of stay, and avoidance of hospital-led infections that may result in financial penalties. Currently, CAUTI is a serious problem in the hospital. Many patients transferred from the intensive care unit (ICU) still have their Foley catheters in. Similarly, there are several patients whose catheters are not discontinued in time, leading to longer hospital stays, hence risking urinary tract infections. Currently, nurses have raised a lot of concerns on the issue, with most of them taking steps to look at patients’ medical records to identify why the catheter is still on and offer the necessary support. Implementing an algorithm-based Foley assessment tool built on the hospital’s EMR can greatly help nurses discontinue catheters on time to avoid CAUTI cases in the hospital.

Hospital SWOT Analysis

According to Bull et al. (2008), SWOT analysis is a powerful strategic tool through which an organization identifies and accesses its strengths, weaknesses, opportunities, and threats. The technique allows healthcare leaders to identify areas of vulnerability, explore areas of improvement, and act as a resource allocation tool. The following section discusses a SWOT analysis of the Veterans Hospital, identifying the facility’s key strengths, weaknesses, opportunities, and threats.


Staff excellent communications skills. The staff at the hospital have excellent communication skills, allowing them to talk to the patients professionally. In most instances, the patients’ affairs office can talk to patients, address their concerns effectively, and assist them in solving their problems.

Wide range of services. The hospital has grown to become a preferred healthcare facility by the community by offering a wide range of services. The hospital can offer quality services to a diverse range of patients and a team of skilled professionals.

Big brand. Due to the excellent services offered at the hospital, the facility has built a strong brand name. Such a brand sets the hospital apart from other community hospitals. The facility is known for its patient-centric policies that place service quality above profitability.

Government Support. Being a veterans’ hospital, the facility receives support from the federal government in the form of grants and subsidies. This helps in reducing the cost of providing care to our patients.


The high cost of care. The world-class services offered at the hospital come with a high price, which most customers find unaffordable, especially those who find difficulties accessing their insurance covers. As a result, the hospital is not always the first choice for the common people. As such, the hospital needs to implement cost-cutting policies, such as reducing the length of stay.

Inadequate Nursing Staff: Nursing staff shortage leads to long working hours and burnouts, which, in turn, compromise the hospital’s ability to offer high-quality services.


Reduced cost of care can attract more patients. There is still room for reducing the cost of care by implementing cost-cutting policies and enhancing efficacy. Such actions will attract more patients from diverse economic statuses. Similarly, reducing the cost of care will help the hospital build a competitive advantage.

Increased demand for quality services. The number of patients demanding improved services and the value of money is increasing every day. Since the hospital focuses on quality over profitability, it will become a preferred hospital for most of these patients.


Competition from evolving hospitals. Due to advancing technology and new medical facilities and interventions, competition is becoming stiff. Such competition will force the hospital to reduce the prices charged in order to retain customers. This will, in turn, lead to reduced revenues.

Financial obligations resulting from court cases: cases of hospital-associated infections in the hospital sometimes lead to hefty financial penalties after courts award huge compensations to patients. Such fines drain the facility financially, hindering its ability to offer quality services.

Perspectives of Stakeholders on the QI Issue

Targeting zero CAUTI cases and culture change regarding catheter use in the hospital requires all stakeholders’ commitment. These stakeholders include registered nurses (RNs), urologists, the infection control team, leadership team, physicians, IT team, and patient care technicians. The QI project would impact patients by decreasing associated complications, increasing patient safety, and reducing LOS. Generally, all stakeholders have indicated a willingness to adopt the new methodologies and protocols as outlined in the quality improvement initiative. Nursing staff will continue adhering to the CAUTI surveillance bundle. On the other hand, physicians and RNs will monitor the need for catheterization. The leadership team will be supporting all the necessary findings for the implemented change (Conway, Pogorzelska, Larson, & Stone, 2012). The hospital management supports the initiative as it helps the hospital improve the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score.  Patients are also optimistic and supportive of the improvement initiatives as it helps reduce the cost of care and promotes their safety.

Current Processes in a Flow Chart

Patient with Indwelling Urethral Catheter (Transfer from ICU)







Assessment on whether the patient remains In Situ

YES                                                                       NO


IUC Continued                                                            IUC is discontinued



Fig 1: The current process chart flow in the hospital

As seen in the flow chart, the process of assessing Foley discontinuation is quite lengthy, which often contributes to a high number of CAUTI cases. Introducing an algorithm-based assessment tool will significantly reduce the process.

Other Factors Affecting the Quality Improvement Issue

Other external factors affect and contribute to the implementation of the QI project targeting the reduction of CAUTI cases. For instance, support from the government significantly contributes to the hospital’s ability to implement the QI project. Similarly, economic factors, such as the availability of the necessary financial resources needed to develop the algorithm-based Foley assessment tool, also affect the hospital’s ability to implement the QI project. The project should also adhere to all existing legal frameworks, especially the laws on data confidentiality (Lo et al., 2014). This owes to the fact that the assessment tool will be integrated into the hospital’s EMR system. Further, the initiative taken should not compromise ethical standards on patient care. All these factors must be considered when implementing the quality improvement project.

Strategies for Improvement using PDSA

This section utilizes the PDSA model to identify the strategies needed to achieve the hospital’s desired quality improvement initiatives. The Plan-Do-Study-Act cycle is a four-stage problem-solving model used in the quality improvement process.

Figure 2: PDSA Cycle




The objective of the quality improvement project is to reduce CAUTI cases by improving staff knowledge on Foley assessment by utilizing an algorithm. The plan is to develop an assessment tool that is integrated with the hospital’s EMR system. The assessment tool will indicate when catheters should be discontinued, hence preventing CAUTI cases that result from Foley overuse. The plan includes RNs, urologists, the infection control team, the leadership team, physicians, the IT team, and patient care technicians (Keyhani, 2016). The implementation and testing phase is expected to be completed within six weeks. By the end of December 2020, we expect the number of cases to have reduced by over 60%. Data will be collected through observation and analysis of medical records on CAUTI cases recorded.


In this phase, the tool will be created by involving the IT team and the physicians. Afterward, RNs will be trained on how to use the tool to assess catheterization protocols. International guidance and PowerPoint presentations will be developed to improve the nursing staff’s engagement and education (Tatham et al., 2015). Practical lessons on how nursing staff can use the Foley assessment tool to indicate catheter discontinuance will be undertaken for three weeks. Afterward, the process will be fully adopted.


Processes in a Flow Chart (After QI Project)

Continuous Assessment using Foley Assessment Tool –Discontinue?
Patient with Indwelling Urethral Catheter (Transfer from ICU)






IUC Discontinued
Continue In  Situ

Continue monitoring

NO                                       YES



Figure 3: Process flow chart after QI Project


Data from the hospital’s medical records will be analyzed weekly after the QI project has been implemented to ensure that the assessment tool is achieving the set objectives. Data on the number of CAUTI cases recorded will be analyzed weekly and compared with cases before the QI project. If the cases are found to have reduced by over 80% within four weeks, the project will be termed as successful.


Depending on the results of the data analyzed, some changes may become necessary. For instance, if the cases do not reduce by 80% as anticipated, more robust training will need to be undertaken. Further, there might be a need to bring in the developers of the program to work hand-in-hand with the nursing staff for three weeks to foster understanding.


QI entails a series of continuous and systematic actions that result in measurable improvements in the health status of the targeted patient population and health services. Continuous improvement is necessitated by mounting pressure to improve the quality of care while maintaining a high level of efficiency and cutting costs. The QI project aims at suppressing the number of catheter-associated urinary tract infections (CAUTI) in the hospital. Currently, CAUTI is a serious problem in the hospital, as many patients transferred from the intensive care unit (ICU) still have their Foley catheters in. The team proposes to implement an algorithm-based urinary catheter (Foley) assessment tool able to indicate catheter discountenance among the patients to address the issue. The Foley assessment tool would be built in the hospital’s electronic medical records (EMR). The PDSA has identified the strategies needed to achieve the desired quality improvement initiatives at the hospital.





Bell, M. M., Alaestante, G., & Finch, C. (2016). A multidisciplinary intervention to prevent catheter-associated urinary tract infections using education, continuum of care, and systemwide buy-in. Ochsner Journal16(1), 96-100.

Bull, J. W., Jobstvogt, N., Böhnke-Henrichs, A., Mascarenhas, A., Sitas, N., Baulcomb, C., … & Carter-Silk, E. (2016). Strengths, weaknesses, opportunities, and threats: A SWOT analysis of the ecosystem services framework. Ecosystem services17, 99-111.

Conway, L. J., Pogorzelska, M., Larson, E., & Stone, P. W. (2012). Adoption of policies to prevent catheter-associated urinary tract infections in United States intensive care units. American Journal of Infection Control40(8), 705-710.

Davis, K. F., Colebaugh, A. M., Eithun, B. L., Klieger, S. B., Meredith, D. J., Plachter, N., … & Coffin, S. E. (2014). Reducing catheter-associated urinary tract infections: a quality-improvement initiative. Pediatrics134(3), e857-e864.

Keyhani, M. (2016). Implementing Ways to Reduce Catheter-associated Urinary Infections (CAUTIs). The University of San Francisco USF Scholarship: A digital repository @ Gleeson Library | Geschke Center

Lo, E., Nicolle, L. E., Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J., … & Yokoe, D. S. (2014). Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology35(S2), S32-S47. Walden University ScholarWorks

Tatham, M., Macfarlane, G., MacRae, M., Tully, V., & Craig, K. (2015). Development and Implementation of a Catheter-Associated Urinary Tract Infection (CAUTI)’Toolkit’. BMJ Open Quality4(1).

Theobald, C. N., Resnick, M. J., Spain, T., Dittus, R. S., & Roumie, C. L. (2017). A multifaceted quality improvement strategy reduces the risk of catheter-associated urinary tract infection. International Journal for Quality in Health Care29(4), 564-570.

Wright, M. (2019). Decreasing Catheter-Associated Urinary Tract Infections in the Acute Care Setting.