MultiCare Deaconess Hospital over one year without any CAUTI infection

March 12, 2020

MultiCare Deaconess Hospital continues to be a high achiever with over one year and 2 months without a single CAUTI infection. MultiCare Deaconess’s success is based on using AHRQ’s (Agency for Healthcare Research and Quality) Comprehensive Unit-based Safety Program (CUSP). CUSP has been proven to dramatically reduce HAIs using evidence-based clinical interventions and building a culture of prevention. MultiCare Deaconess is a great example of adopting a model to improve their CAUTI infection rates and sustain their progress by monitoring their outcomes. Additionally, they are a model for other hospitals by sharing their success strategies throughout the Puget Sound region and across the nation as part of the American Hospital Association’s (AHA) HRET (Health Research and Educational Trust) ICU Safety Program using CUSP.

MultiCare Deaconess Hospital’s administration and staff exemplified a committed approach in the improvement of infections by bringing on a seasoned clinical nurse specialist (CNS) to ensure sustainability of infection prevention for CAUTI and other HAIs. The clinical nurse specialist will promote staff engagement by training others to spread best practices and sustaining the culture of safety throughout the organization. The quality nurse officer asked the ICU team to assist other hospital units and develop the same approach in reducing CAUTIs due to their great job reducing CAUTIs using CUSP and WSHA invited the ICU team from MultiCare Deaconess to participate in the onsite DELTA Day workshop.

Participants to the DELTA Day came from Alaska, Washington, and Oregon. The MultiCare Deaconess ICU team inspired other hospitals with their success story. Participants learned that they achieved success through supportive administrators and leaders, ICU ownership, and unit leaders. Ideas about how to be creative and use humor to accomplish this important work were also shared. WSHA assisted MultiCare Deaconess by providing monthly coaching calls, understanding the needs and challenges of the ICU staff, and monitoring staff’s progress in reducing CAUTI infections. WSHA also facilitated the spread of MultiCare Deaconess Hospital’s exuberance and success to other facilities across the region and nation as part of the AHA/HRET program.

Infection prevention bundles have been available to hospitals for some time; however, CUSP is the key ingredient in reduction of HAIs and is different from other change models because it makes its tools relevant to clinicians by putting them in the context of a hospital environment at a unit level. WSHA is uniquely positioned to help hospitals achieve reduction of infections and wants to spread evidence-based programs, such as CUSP, with other hospitals across the region. The WSHA infection team has since created their own CUSP Cohort and expanded their program to address additional infections, i.e., ventilator associated events, Clostridioides difficile and surgical site infections. For more information on CUSP, please reach out to Sandra Assasnik at


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