Funding Learning Health System Research: Challenges and Strategies.

PURPOSE: A growing number of health systems are establishing learning health system (LHS) programs, where research focuses on rapidly improving the health system's internal operations and performance. The authors examine funding challenges facing such initiatives and identify strategies for managing tensions between reliance on external research funding and directly contributing to improvement and learning within the researchers' own system. METHOD: Qualitative case studies of LHS research programs in 5 health systems were performed via 38 semistructured interviews (October 2019-April 2021) with 35 diverse respondents. Inductive and deductive rapid qualitative analysis supported interview, system-level, and cross-system summaries and analysis. RESULTS: External funding awards to LHS researchers facilitated some internal improvement and learning, scientific advancements, and the reputation of researchers and their systems, but reliance on external funding also challenged researchers' responsiveness to concerns of system leaders, managers, practitioners, and system needs. Gaps between external funding requirements and internally focused projects arose in objectives, practical applicability, audiences, timetables, routines, skill sets, and researchers' careers. To contribute more directly to system improvement, LHS researchers needed to collaborate with clinicians and other nonresearchers and pivot between long research studies and shorter, dynamic improvement, evaluation, and data analysis projects. With support from system executives, LHS program leaders employed several strategies to enhance researchers' internal contributions. They aligned funded-research topics with long-term system needs, obtained internal funding for implementing and sustaining practice change, and diversified funding sources. CONCLUSIONS: To foster LHS research contributions to internal system learning and improvement, LHS program leaders need to manage tensions between concentrating on externally funded research and fulfilling their mission of providing research-based services to their own system. Health system executives can support LHS programs by setting clear goals for them; appropriately staffing, budgeting, and incentivizing LHS researchers; and developing supportive, system-wide teamwork, skill development programs, and data infrastructures.

How alignment between health systems and their embedded research units contributes to system learning.

BACKGROUND: There is growing interest in the contributions of embedded, learning health system (LHS), research within healthcare delivery systems. We examined the organization of LHS research units and conditions affecting their contributions to system improvement and learning. METHODS: We conducted 12 key-informant and 44 semi-structured interviews in six delivery systems engaged in LHS research. Using rapid qualitative analysis, we identified themes and compared: successful versus challenging projects; LHS units and other research units in the same system; and LHS units in different systems. RESULTS: LHS units operate both independently and as subunits within larger research centers. Contributions of LHS units to improvements and learning are influenced by alignment of facilitating factors within units, within the broader system, and between unit and host system. Key alignment factors were availability of internal (system) funding directing researchers' work toward system priorities; researchers' skills and experiences that fit a system's operational needs; LHS unit subculture supporting system improvement and collaboration with clinicians and other internal stakeholders; applications of external funding to system priorities; and executive leadership for system-wide learning. Mutual understanding and collaboration between researchers, clinicians, and leaders was fostered through direct consultation between LHS unit leaders and system executives and engagement of researchers in clinical and operational activities. CONCLUSIONS: Embedded researchers face significant challenges to contributing to system improvement and learning. Nevertheless, when appropriately led, organized, and supported by internal funding, they may learn to collaborate effectively with clinicians and system leaders in advancing care delivery toward the learning health system ideal.

Integrating a Patient Engagement App into an Electronic Health Record-Enabled Workflow Using Interoperability Standards.

BACKGROUND: Patient use of mobile health applications is increasing. To promote patient-centered care, data from these apps must be integrated into clinician workflows within the electronic health record (EHR). Health Level 7 Fast Healthcare Interoperability Resources (FHIR) offers a standards-based application programming interface (API) that may support such integration. OBJECTIVE: We aimed to use interoperability standards to integrate a patient mobile application (coronavirus 2019 [COVID-19] Tracker) with an EHR. The COVID-19 Tracker engages patients by sending introductory and reminder text messages, collecting vital signs and symptom data from COVID-19 patients, and providing actionable guidance if concerning issues are identified. This case report explored the use of FHIR APIs to integrate the app into EHR-enabled clinical workflows. METHODS: The authors used notes from project meetings and from semistructured discussions among the application development team to track the design and implementation processes. Seven points of integration between the application and the EHR were identified, and approaches using FHIR to perform these integrations were delineated. RESULTS: Although this clinical decision support integration project benefited from its standards-based approach, many challenges were encountered. These were due to (1) partial implementation of the FHIR standard in the EHR, particularly, components needed for patient engagement applications; (2) limited experience with the adoption of FHIR standards; and (3) gaps in the current FHIR standard. Alternative approaches, often not based on interoperability standards, were developed to overcome these limitations. CONCLUSION: Despite the challenges encountered due to the early stages of FHIR development and adoption, FHIR standards provide a promising mechanism for overcoming longstanding barriers and facilitating the integration of patient engagement apps with EHRs. To accelerate the integration of apps into clinical workflows, additional components of the FHIR standard must be implemented within the EHR and other clinical systems. Continued expansion of available FHIR resources will help with tighter workflow integration.

Challenges and opportunities for advancing patient-centered clinical decision support: findings from a horizon scan.

OBJECTIVE: We conducted a horizon scan to (1) identify challenges in patient-centered clinical decision support (PC CDS) and (2) identify future directions for PC CDS. MATERIALS AND METHODS: We engaged a technical expert panel, conducted a scoping literature review, and interviewed key informants. We qualitatively analyzed literature and interview transcripts, mapping findings to the 4 phases for translating evidence into PC CDS interventions (Prioritizing, Authoring, Implementing, and Measuring) and to external factors. RESULTS: We identified 12 challenges for PC CDS development. Lack of patient input was identified as a critical challenge. The key informants noted that patient input is critical to prioritizing topics for PC CDS and to ensuring that CDS aligns with patients' routine behaviors. Lack of patient-centered terminology standards was viewed as a challenge in authoring PC CDS. We found a dearth of CDS studies that measured clinical outcomes, creating significant gaps in our understanding of PC CDS' impact. Across all phases of CDS development, there is a lack of patient and provider trust and limited attention to patients' and providers' concerns. DISCUSSION: These challenges suggest opportunities for advancing PC CDS. There are opportunities to develop industry-wide practices and standards to increase transparency, standardize terminologies, and incorporate patient input. There is also opportunity to engage patients throughout the PC CDS research process to ensure that outcome measures are relevant to their needs. CONCLUSION: Addressing these challenges and embracing these opportunities will help realize the promise of PC CDS-placing patients at the center of the healthcare system.

The technical landscape for patient-centered CDS: progress, gaps, and challenges.

Supporting healthcare decision-making that is patient-centered and evidence-based requires investments in the development of tools and techniques for dissemination of patient-centered outcomes research findings via methods such as clinical decision support (CDS). This article explores the technical landscape for patient-centered CDS (PC CDS) and the gaps in making PC CDS more shareable, standards-based, and publicly available, with the goal of improving patient care and clinical outcomes. This landscape assessment used: (1) a technical expert panel; (2) a literature review; and (3) interviews with 18 CDS stakeholders. We identified 7 salient technical considerations that span 5 phases of PC CDS development. While progress has been made in the technical landscape, the field must advance standards for translating clinical guidelines into PC CDS, the standardization of CDS insertion points into the clinical workflow, and processes to capture, standardize, and integrate patient-generated health data.

Multi-level analysis of the learning health system: Integrating contributions from research on organizations and implementation.

INTRODUCTION: Organizations and systems that deliver health care may better adapt to rapid change in their environments by acting as learning organizations and learning health systems (LHSs). Despite widespread recognition that multilevel forces shape capacity for learning within care delivery organizations, there is no agreed-on, comprehensive, multilevel framework to inform LHS research and practice. METHODS: We develop such a framework, which can enhance both research on LHSs and practical steps toward their development. We draw on existing frameworks and research within organization and implementation science and synthesize contributions from three influential frameworks: the Consolidated Framework for Implementation Research, the social-ecological framework, and the organizational change framework. These frameworks come, respectively, from the fields of implementation science, public health, and organization science. RESULTS: Our proposed integrative framework includes both intraorganizational levels (individual, team, mid-management, organization) and the operating and general environments in which delivery organizations operate. We stress the importance of examining interactions among influential factors both within and across system levels and focus on the effects of leadership, incentives, and culture. Additionally, we indicate that organizational learning depends substantially on internal and cross-level alignment of these factors. We illustrate the contribution of our multilevel perspective by applying it to the analysis of three diverse implementation initiatives that aimed at specific care improvements and enduring system learning. CONCLUSIONS: The framework and perspective developed here can help investigators and practitioners broadly scan and then investigate forces influencing improvement and learning and may point to otherwise unnoticed interactions among influential factors. The framework can also be used as a planning tool by managers and practitioners.

Use of Internal Performance Measurement to Guide Improvement Within Medical Groups.

BACKGROUND: Public reporting of provider performance currently encompasses a range of measures of quality, cost, and patient experience of care. However, little is known about how medical groups use measures for performance improvement. This information could help medical groups undertake internal measurement while helping payers, policy makers, and measurement experts develop more useful publicly reported measures and quality improvement strategies. METHODS: An exploratory, qualitative study was conducted of ambulatory care medical groups across the United States that currently gather their own performance data. RESULTS: Eighty-three interviews were conducted with 91 individuals representing 37 medical groups. Findings were distilled into three major themes: (1) measures used internally, (2) strategies for using internal measurement for performance improvement, and (3) other uses of internal measurement. Medical groups used both clinical and business process measures, including measures from external measure sets and internally derived measures. Strategies for using internal measurement for quality improvement included taking a gradual, iterative approach and setting clear goals with high priority, finding workable approaches to data sharing, and fostering engagement by focusing on actionable measures. Measurement was also used to check accuracy of external performance reports, clarify and manage conflicting external measurement requirements, and prepare for anticipated external measurement requirements. Respondents in most groups did not report a need to assess costs of internal measurement or the capacity to do so. CONCLUSION: Despite challenges and barriers, respondents found great value in conducting internal measurement. Their experiences may provide valuable lessons and knowledge for medical group leaders in earlier stages of establishing internal measurement programs.

Contextual Conditions and Performance Improvement in Primary Care.

BACKGROUND: Although organizational context can affect the implementation of quality initiatives, we know less about the influence of contextual conditions on quality outcomes. We examined organizational features of primary care clinics that achieved greatest performance improvements after implementing Lean redesigns. METHODS: We used operational data and baseline (ie, pre-Lean implementation) surveys of 1333 physicians and staff in 43 primary care clinics located across a large ambulatory care system. Segmented regression with interrupted time series analysis was used to identify clinics with highest improvements in workflow efficiency, physician productivity, and patient satisfaction following Lean redesign. We conducted independent-samples t tests to identify contextual features of clinics that showed greatest improvements in performance outcomes. RESULTS: Clinics with highest increases in efficiency had most prior experience with quality improvement, compared with all other clinics. Efficiency gains were also found in clinics reporting highest levels of burnout and work stress prior to redesign. Highest improvements in physician productivity were associated with a history of change, staff participation, and leadership support for redesigns. Greatest improvements in patient satisfaction occurred in least stressful environments with highest levels of teamwork, staff engagement/efficacy, and leadership support. CONCLUSIONS: Our findings encourage careful evaluation of clinic characteristics and capacity to effectively implement redesigns. Such evaluations may help leaders select interventions most appropriate for certain clinics, while identifying others that may need extra support with implementing change.

Sustainment of Lean Redesigns for Primary Care Teams.

BACKGROUND: Quality improvements are notoriously followed by "backsliding" or relapse to the status quo. This mixed-methods study examined the sustainment of Lean workflow redesigns for primary care teams several years after being implemented in a large, ambulatory care delivery system. METHODS: We conducted qualitative interviews of 57 leaders and frontline providers, and fielded post-Lean implementation surveys to 1164 physicians and staff in 17 primary care clinics across the system. We analyzed interviews and conducted independent sample t tests to identify key factors that facilitated the sustainment of new workflows among primary care teams. All analyses were conducted after Lean redesigns were implemented and scaled across the system in 3 consecutive phases. RESULTS: Adherence to Lean redesigns was highest in the pilot clinic, despite having the longest postdesign measurement period. Members of the pilot clinic reported greatest participation in designing workflows, were most highly engaged in quality improvement efforts, and held most favorable beliefs about Lean changes. Adherence to redesigns was lowest among clinic members in the second phase of implementation; these members also reported highest levels of burnout. CONCLUSIONS: Staff participation in Lean redesign is a key to facilitating buy-in and adherence to changes. Change ownership and continued availability of time for improvement activities are also critical to the long-term success of Lean implementation in primary care.

Experiences of primary care physicians and staff following lean workflow redesign.

BACKGROUND: In response to growing pressures on primary care, leaders have introduced a wide range of workforce and practice innovations, including team redesigns that delegate some physician tasks to nonphysicians. One important question is how such innovations affect care team members, particularly in view of growing dissatisfaction and burnout among healthcare professionals. We examine the work experiences of primary care physicians and staff after implementing Lean-based workflow redesigns. This included co-locating physician and medical assistant dyads, delegating significant responsibilities to nonphysician staff, and mandating greater coordination and communication among all care team members. METHODS: The redesigns were implemented and scaled in three phases across 46 primary care departments in a large ambulatory care delivery system. We fielded 1164 baseline and 1333 follow-up surveys to physicians and other nonphysician staff (average 73% response rate) to assess workforce engagement (e.g., job satisfaction, motivation), perceptions of the work environment, and job-related burnout. We conducted multivariate regressions to detect changes in experiences after the redesign, adjusting for respondent characteristics and clustering of within-clinic responses. RESULTS: We found that both physicians and nonphysician staff reported higher levels of engagement and teamwork after implementing redesigns. However, they also experienced higher levels of burnout and perceptions of the workplace as stressful. Trends were the same for both occupational groups, but the increased reports of stress were greater among physicians. Additionally, members of all clinics, except for the pilot site that developed the new workflows, reported higher burnout, while perceptions of workplace stress increased in all clinics after the redesign. CONCLUSIONS: Our findings partially align with expectations of work redesign as a route to improving physician and staff experiences in delivering care. Although teamwork and engagement increased, the redesigns in our study were not enough to moderate long-standing challenges facing primary care. Yet higher levels of empowerment and engagement, as observed in the pilot clinic, may be particularly effective in facilitating improvements while combating fatigue. To help practices cope with increasing burdens, interventions must directly benefit healthcare professionals without overtaxing an already overstretched workforce.

Implementation of Care Management: An Analysis of Recent AHRQ Research.

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

Learning from implementation setbacks: Identifying and responding to contextual challenges.

Introduction: We address organizational learning about implementation context during setbacks to primary care redesign in an ambulatory system. The redesign expanded care teams and added a medical assistant assigned administrative and coordination tasks. The redesign was expected to improve care efficiency, prevention, and continuity. In response to setbacks, redesign and system leaders used understanding of context to plan system-wide changes, as well as program adjustments. Doing so enhanced the redesign's prospects and contributed to system learning. Methods: We conducted a 33-month, mixed-methods study. Qualitative data included quarterly calls with the redesign leaders and 63 activity log entries. There were three site visits; 73 interviews with practice leaders, providers, and medical assistants. Data analysis used categories from an implementation research framework; these were refined and then expanded inductively using log reports, debriefings with change leaders, and documents. Quantitative analysis used system operational data on chronic care, prevention, efficiency, productivity, and patient access. Results: Redesigned teams were not implemented as widely or rapidly as anticipated and did not deliver hoped-for gains in operational metrics. Interviews reported that team redesign was leading to improvements in chronic care and prevention and eased provider burden. Besides making small adjustments to cope with setbacks, redesign and system leaders engaged in more thorough organizational learning. They examined contextual challenges underlying setbacks and posing risks to the delivery system as a whole. Their responses to challenges helped strengthen the redesign's prospects, improved the delivery system's position in its labor market, and helped the system prepare to meet emerging requirements for value-based care and population health. Conclusions: This case points to benefits for both health care researchers and change practitioners of paying closer attention to how context affects implementation of organizational change, and to opportunities and conditions for learning from setbacks during change.

Scaling Lean in primary care: impacts on system performance.

OBJECTIVES: We examined a wide range of performance outcomes after Lean methodology-a leading strategy to enhance efficiency and patient value-was implemented and scaled across all primary care clinics in a nonprofit, ambulatory care delivery system. STUDY DESIGN: Using a stepped wedge approach, we assessed changes associated with the phased introduction of Lean-based redesigns across 46 primary care departments in 17 different clinic locations. Longitudinal analysis of operational metrics included: workflow efficiency, physician productivity, operating expenses, clinical quality, and satisfaction among patients, physicians, and staff. METHODS: We used interrupted time series analysis with generalized linear mixed models to estimate Lean impacts over time. Projected outcomes in the absence of changes (ie, counterfactuals) were compared with observed outcomes after Lean redesigns were implemented, and mean differences were assessed using 95% bias-corrected bootstrap confidence intervals (CIs). RESULTS: We observed systemwide improvements in workflow efficiencies (eg, 95% CI, 5.8-10.4) and physician productivity (95% CI, 3.9-27.2), with no adverse effects on clinical quality. Patient satisfaction increased with respect to access to care (95% CI, 15.2-20.7), handling of personal issues (95% CI, 2.1-6.9), and overall experience of care (95% CI, 11.0-17.0), but decreased with respect to interactions with care providers (95% CI, -13.4 to -5.7). Departmental operating costs decreased, and annual staff and physician satisfaction scores increased particularly among early adopters, with key improvements in employee engagement, connection to purpose, relationships with staff, and physician time spent working. CONCLUSIONS: Lean redesigns can benefit primary care patients, physicians, and staff without negatively impacting the quality of clinical care. Study results may lead other delivery system leaders to innovate using Lean techniques and may further enhance support for Lean learning among public and private payers.

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review.

BACKGROUND: The Improving Diagnosis in Health Care report from the National Academies of Sciences, Engineering and Medicine (NASEM) provided an opportunity for many groups to reflect on the role they could play in taking actions to improve diagnostic safety. As part of its own process, AHRQ held a research summit in the fall of 2016, inviting members from a diverse collection of organizations, both inside and outside of Government, to share their suggestions regarding what is known about diagnosis and the challenges that need to be addressed. CONTENT: The goals of the summit were to learn from the insights of participants; examine issues associated with definitions of diagnostic error and gaps in the evidence base; explore clinician and patient perspectives; gain a better understanding of data and measurement, health information technology, and organizational factors that impact the diagnostic process; and identify potential future directions for research. Summary and outlook: Plenary sessions focused on the state of the new diagnostic safety discipline followed by breakout sessions on the use of data and measurement, health information technology, and the role of organizational factors. The proceedings review captures many of the key challenges and areas deserving further research, revealing stimulating yet complex issues.

Acceptance of lean redesigns in primary care: A contextual analysis.

BACKGROUND: Lean is a leading change strategy used in health care to achieve short-term efficiency and quality improvement while promising longer-term system transformation. Most research examines Lean intervention to address isolated problems, rather than to achieve broader systemic changes to care delivery. Moreover, no studies examine contextual influences on system-wide Lean implementation efforts in primary care. PURPOSE: The aim of this study was to identify contextual factors most critical to implementing and scaling Lean redesigns across all primary care clinics in a large, ambulatory care delivery system. METHODOLOGY/APPROACH: Over 100 interviews and focus groups were conducted with frontline physicians, clinical staff, and operational leaders. Data analysis was guided by a modified Consolidated Framework for Implementation Research (CFIR), a popular implementation science framework. On the basis of expert recommendations, the modified framework targets factors influencing the implementation of process redesigns. This modified framework, the CFIR-PR, informed our identification of contextual factors that most impacted Lean acceptance among frontline physicians and staff. FINDINGS: Several domains identified by the CFIR-PR were critical to acceptance of Lean redesigns. Regarding the implementation process acceptance was influenced by time and intensity of exposure to changes, "top-down" versus "bottom-up" implementation styles, and degrees of employee engagement in developing new workflows. Important factors in the inner setting were the clinic's culture and style of leadership, along with availability of information about Lean's effectiveness. Last, implementation efforts were impacted by individual and team characteristics regarding changed work roles and related issues of professional identity, authority, and autonomy. PRACTICE IMPLICATIONS: This study underscores the need for change leaders to consider the contextual factors that surround efforts to implement Lean in primary care. As Lean redesigns are scaled across a system, special attention is warranted with respect to the implementation approach, internal clinic setting, and implications for professional roles and identities of physicians and staff.

Medical Assistants as Flow Managers in Primary Care: Challenges and Recommendations.

As healthcare organizations look for ways to reduce costs and improve quality, many rely increasingly on allied healthcare professionals and, in particular, medical assistants (MAs) to supplement the work of physicians and other health professionals. MAs usually work in primary care, where they often play important roles on healthcare teams. Drawing on an empirical study of a large, multispecialty delivery system engaged in reconfiguration of primary care, we found that using MAs as flow managers required overcoming several challenges. These included entrenched social and occupational hierarchies between physicians and MAs, a lack of adequate training and mentorship, and difficulty attracting and retaining talented MAs. We offer several recommendations for healthcare organizations interested in using MAs as flow managers in their practices.

Effects of organizational context on Lean implementation in five hospital systems.

BACKGROUND: Despite broad agreement among researchers about the value of examining how context shapes implementation of improvement programs and projects, limited attention has been paid to contextual effects on implementation of Lean. PURPOSE: To help reduce gaps in knowledge of effects of intraorganizational context, we researched Lean implementation initiatives in five organizations and examined 12 of their Lean rapid improvement projects. All projects aimed at improving clinical care delivery. METHODOLOGY/APPROACH: On the basis of the literature on Lean, innovation, and quality improvement, we developed a framework of factors likely to affect Lean implementation and outcomes. Drawing on the framework, we conducted semistructured interviews and applied qualitative codes to the transcribed interviews. Available documents, data, and observations supplemented the interviews. We constructed case studies of Lean implementation in each organization, compared implementation across organizations, and compared the 12 projects. FINDINGS: Intraorganizational characteristics affecting organization-wide Lean initiatives and often also shaping project outcomes included CEO commitment to Lean and active support for it, prior organizational capacity for quality improvement-based performance improvement, alignment of the Lean initiative with the organizational mission, dedication of resources and experts to Lean, staff training before and during projects, establishment of measurable and relevant project targets, planning of project sequences that enhance staff capabilities and commitment without overburdening them, and ensuring communication between project members and other affected staff. Dependence of projects on inputs of new information technology was a barrier to project success. Incremental implementation of Lean produced reported improvements in operational efficiency and occasionally in care quality. However, even under the relatively favorable circumstances prevailing in our study sites, incremental implementation did not readily change organizational culture. PRACTICE IMPLICATIONS: This study should alert researchers, managers, and teachers of management to ways that contexts shape Lean implementation and may affect other types of process redesign and quality improvement.

Preventing central line-associated bloodstream infections: a qualitative study of management practices.

OBJECTIVE: To identify factors that may explain hospital-level differences in outcomes of programs to prevent central line-associated bloodstream infections. DESIGN: Extensive qualitative case study comparing higher- and lower-performing hospitals on the basis of reduction in the rate of central line-associated bloodstream infections. In-depth interviews were transcribed verbatim and analyzed to determine whether emergent themes differentiated higher- from lower-performing hospitals. SETTING: Eight US hospitals that had participated in the federally funded On the CUSP-Stop BSI initiative. PARTICIPANTS: One hundred ninety-four interviewees including administrative leaders, clinical leaders, professional staff, and frontline physicians and nurses. RESULTS: A main theme that differentiated higher- from lower-performing hospitals was a distinctive framing of the goal of "getting to zero" infections. Although all sites reported this goal, at the higher-performing sites the goal was explicitly stated, widely embraced, and aggressively pursued; in contrast, at the lower-performing hospitals the goal was more of an aspiration and not embraced as part of the strategy to prevent infections. Five additional management practices were nearly exclusively present in the higher-performing hospitals: (1) top-level commitment, (2) physician-nurse alignment, (3) systematic education, (4) meaningful use of data, and (5) rewards and recognition. We present these strategies for prevention of healthcare-associated infection as a management "bundle" with corresponding suggestions for implementation. CONCLUSIONS: Some of the variance associated with CLABSI prevention program outcomes may relate to specific management practices. Adding a management practice bundle may provide critical guidance to physicians, clinical managers, and hospital leaders as they work to prevent healthcare-associated infections.