Program Benefits, Overview, and Structure
Eligibility
Join the Program
Data Collection
Data Use and Privacy
Educational Webinars and Program Activities
Program Benefits, Overview, and Structure
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What are the benefits of participating?
The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Healthcare-Associated Infection (HAI) Prevention: Central Line-Associated Bloodstream Infections (CLABSI) team will work closely with your hospital staff to develop or enhance the approaches your hospital takes to optimize infection prevention. Using evidence-based, scientific, practical implementation strategies, we can help members of your hospital promote evidence-based practices for CLABSI prevention.
This unit-based program will help you improve teamwork, communication, and the understanding and implementation of patient safety culture in participating hospital units. It will also take you through the process of developing solutions for patient safety issues in the units. Together, these approaches will improve staff knowledge of infection prevention and help them identify approaches to successfully reduce and prevent CLABSI.
This program offers access to renowned clinical subject matter experts in HAI and CLABSI prevention and the science of patient safety and quality improvement in real-world settings. Your hospital units will have access to these experts through one-on-one technical assistance, coaching, and ongoing education.
By participating, your hospital unit(s) will—
- Reduce hospital CLABSI rates
- Promote and improve infection prevention procedures
- Enhance teamwork and communication around diagnosis of CLABSI in your unit
- Improve patient safety and safety culture
- Receive regular benchmarking reports that compare unit progress to those of similar units
- Be eligible to receive free continuing education units (CEUs) and continuing medical education (CME) credits
Visit the Eligibility FAQ section or the Join the Program page to find out if you qualify to participate in the program.
Will CME and CEU credits be awarded for participation?
Yes, continuing education units (CEUs) and continuing medical education (CME) credits will be available at no cost for participating physicians, physician assistants, pharmacists, nurse practitioners, and registered nurses who engage in the care of patients.
Who is sponsoring the program?
This program is funded and guided by the Agency for Healthcare Research and Quality (AHRQ), which is part of the U.S. Department of Health and Human Services (HHS). NORC at the University of Chicago is conducting the work in collaboration with Johns Hopkins University. Together, they are the National Program Team.
What is the timeline for the program?
This program runs for 9 months, beginning in July 2025, followed by an additional month of data submission. Key dates include:
- Participate in the program: July 2025 through March 2026
- Submit data: July 2025 through April 2026
What is required of our unit to participate in the program?
Expected activities include the following:
- Participate in regular educational webinars (about 30 minutes each). Participants will receive monthly training via webinars, which are held live and posted online for self-paced learning. Webinars will be offered at various times so that staff can participate at a time convenient for them.
- Check-in with an Implementation Adviser. Each unit will be paired with an Implementation Adviser, a quality improvement expert who will provide technical assistance to facilitate implementation measures and best practices, help troubleshoot challenges, and support data collection through monthly check-in meetings.
- Participate in coaching calls. Optionally attend live coaching calls with program staff and subject matter experts to ask questions and learn from peers.
- Determine and implement approaches to improve infection prevention. Using approaches discussed in the webinars, units will develop and implement strategies to identify and prevent device-associated HAIs including implementation of evidence-based insertion and maintenance bundles, daily assessments of continued need for devices, and approaches to select and secure devices. In addition, units will use process measure auditing tools, checklists, and guides for performing root cause analyses for device-associated HAIs.
- Collect and review data. Units will be asked to complete several surveys throughout the program. Units may also be asked to extract device-associated HAI data from their electronic health record (EHR).
Who should be on the team for the program?
Each unit should identify a physician/advanced practitioner and nursing leader, an executive/senior leader, and a potential Infection Preventionist to assist with overseeing the work. Additional team members can include other physicians, physician assistants, nurse practitioners, infectious disease attending physicians, patient care technicians, environmental services staff, clinical pharmacists, or house staff/fellows.
How much time will the program take our staff?
We anticipate unit staff will spend 2 hours per month on the AHRQ Safety Program for HAI Prevention, participating in educational webinars, coaching calls, and team meetings. Unit Leads may devote an additional 2 hours each month to collect and submit data. Please refer to the Data Collection FAQ section for more information.
Eligibility
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Who is eligible to participate?
Intensive care units (ICUs) and non-ICUs motivated in preventing CLABSI are eligible and encouraged to participate in the AHRQ Safety Program for HAI Prevention. ICUs and non-ICUs that care for adult medical and surgical patients are eligible to participate in this free, 9-month program. To participate in the program, hospitals must meet the following criteria:
Eligibility
| CLABSI Eligibility |
Purpose |
| Hospital Type |
Acute care hospitals |
| Location |
Based in the United States or U.S. territories (rural, urban, or suburban) |
| Size |
Minimum of 50 beds |
| Electronic Health Record |
Requires an EHR. Any EHR vendor is eligible. |
| Unit Type |
ICUs and non-ICUs are eligible to participate. This includes adult critical care units (e.g., medical critical care, respiratory critical care, surgical critical care, trauma critical care); adult wards (e.g., medical ward, medical-surgical ward, surgical ward); and step-down/intermediate care units. |
| Unit Specifications |
Adult care, inpatient, overnight stay unit (i.e., patients stay overnight, predominantly more than 48 hours).
≥5 beds |
My hospital has multiple locations/facilities. Does each location have to apply separately?
If your hospital has multiple locations/facilities you would like to enroll in the program, please contact the National Program Team at safetyprogram4hai-prevention@norc.org.
Join the Program
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How do I apply for the program?
To apply for the CLABSI program, complete the online application found on the Join the Program page.
The deadline to apply is June 30, 2025.
How many units will participate in the program?
Up to 150 ICUs and non-ICUs across the United States will participate in the CLABSI program.
What does it cost for our hospital to participate in the program?
Participation in the program is free. Participating hospitals and units will not incur any fees to receive assistance as a part of this program and will not receive any payment for participation.
What materials do I need to complete before the program begins?
You need to complete the online application and a Commitment Form for the units you would like to enroll in the program. The application requests information about your hospital, units to enroll, as well as contact information. After the National Program Team reviews your application, you will receive a Commitment Form, which will need to be signed by a hospital executive/administrator, medical director, and clinician champion.
Do we need IRB approval to participate?
The Johns Hopkins Medicine Institutional Review Board (IRB) has determined this program is not human subjects research under HHS or Food and Drug Administration (FDA) regulations (IRB #IRB00463987). As this program does not involve human subjects research, IRB approval is not required. Your hospital should be able to frame this program as a quality improvement program. If your hospital requires an IRB submission for informational purposes, we will be glad to assist you as needed.
Is a contract required to participate in the program?
No, a contract is not required to participate in the program. To apply for the program, your primary contact will need to complete the online application form available on the Join the Program page.
To participate in the program, we request a Commitment Form signed by a hospital executive/administrator, medical director, and clinician champion. The National Program Team will email you a Commitment Form after your hospital completes the online application. The Commitment Form is not a contract, but rather, an agreement. We ask for these signatures to ensure support for the program from the hospital leadership and to approve the minimum time commitment of 2 hours per month.
Data Collection
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What data will be collected from our hospital?
During the program, participating units will be asked to engage in data collection activities to help understand the program’s impact on culture and optimize infection prevention. Unit Leads will be asked to complete two surveys at the beginning and end of the program, monthly device round surveys, and retrospective and quarterly HAI rate data extracted from electronic health records (alternatively, your unit can confer your National Healthcare Safety Network [NHSN] data to the program to reduce data collection burden). Finally, participants may elect to participate in an interview at the end of the program.
How will unit data be submitted?
Your unit will submit data through the AHRQ Safety Program for HAI Prevention secure data collection portal via structured online forms. Your unit will have the opportunity to confer NHSN data rights to the program to reduce data collection burden.
Data Use and Privacy
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Is a data use agreement (DUA) required to participate in the program?
No, a DUA is not required for participation in the program. The data are being collected both for program assessment purposes and as a tool for each hospital’s own quality improvement efforts. Each hospital should use the data it collects to evaluate its infection prevention efforts. NORC at the University of Chicago and Johns Hopkins University, the program implementers, will use the collected data to assess the adoption and effectiveness of the program overall.
Since the program only requests de-identified information and does not request any protected health information (PHI), program participation does not require a DUA. However, if your hospital determines that it still needs a DUA to define the transaction, we can provide a template for your review.
Will participating hospitals have to provide PHI about their patients?
No. The program only requests de-identified information; it does not request any PHI.
For what purpose will the data be used?
The program is collecting data as a tool for quality improvement efforts and program assessment purposes. Each unit should use the data it collects to evaluate its infection prevention efforts. The National Program Team will use the collected data to assess the adoption and effectiveness of the program overall. Additionally, each unit will receive benchmarking reports to compare its infection prevention data to similar units. The program is collecting only de-identified data and will not identify any individually participating hospitals. The program will share aggregate unit-level infection prevention data with similar participating units for comparison purposes only.
Where specifically will our data be shared, and will it be published with our hospital identifiers?
The program only collects de-identified patient data. Your hospital’s data will be aggregated and anonymized by NORC at the University of Chicago, and then shared only with partners at Johns Hopkins University, the program implementers, and AHRQ. The program will not identify individual participating hospitals.
Educational Webinars and Program Activities
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What topics will the educational webinars cover?
The monthly webinars focus on (1) ways to improve teamwork and communication on a unit, particularly around infection prevention, (2) ways to identify potential harm and reasons for harm associated with devices (i.e., central lines), and (3) discussion of best practices to prevent device-associated infections (e.g., insertion and maintenance of devices, early device removal, device selection). In addition to webinars, the program will provide additional tools and resources to support implementation.
Who should participate in the webinars?
The Unit Leads and Infection Preventionists should participate in the webinars. Clinical staff, particularly those who interact with patients and insert and manage devices, including physicians or advanced practice providers (physician assistants, nurse practitioners, etc.) should also be invited to participate in the webinars. Consider designating at least one or two frontline providers to attend each webinar in real time and report back to the rest of the team on the topic(s) covered. Webinar content will also be available on demand through the program website for asynchronous review.
Are in-person meetings required?
This program does not require any in-person meetings. All program content will be delivered via webinars and program resources. Meetings and communications with the program team (e.g., monthly check-ins with Implementation Advisers, coaching calls with experts) will be held virtually over conference calls, video calls, or email. Internal meetings with team members in your unit may be held in person or virtually.