How to Tackle CLABSI & Take Control of Your Star Ratings

$48,000. According to the CDC, that’s the estimated financial hit a hospital incurs from single CLABSI case*. That doesn’t account for the costly risks, like the HACRP and HVBP penalties or the lower CMS star ratings, that can come with each new infection. (Yes, just one low measure like CLABSI can cost you a star.)

And it certainly doesn’t account for the costs that the patient has to bear. From sepsis to organ failure, each new infection brings with it a high risk for complications that are too devastating to quantify. 

So, it goes without saying that hospitals across the nation are wrestling with the same questions: what are we going to do about CLABSI? Is a zero CLABSI rate really possible? And if so, how can we achieve it? 

In the summer of 2025, one hospital** set out to answer these questions in earnest. We sat down with the hospital’s quality leaders to see exactly what it takes to make zero CLABSI an organization-wide patient safety movement. Here’s what they had to say.

What made your team decide to prioritize CLABSI this year?

Our initial conversations were actually around how we could improve our star ratings and our public reputation. It is important to our hospital that our star ratings are an accurate reflection of our commitment to patient safety and being the provider of choice for the communities we serve. We had been working with Medisolv’s Advisory Services, and they helped us identify CLABSI as one of the primary measures that could drive improvement for us. CLABSI improvement was something we were always working on, and we had been making some progress, just not enough.

What were the first steps you took get your CLABSI priority in motion?

We formed a Zero CLABSI committee that meets bi-weekly, and then worked with Medisolv to conduct a root-cause analysis on the measure. That meant going to the frontline staff to hear directly from them what our problem areas were. We put all our findings from these interviews into a fishbone diagram, which made it easier for us as a committee to debate each issue that had been uncovered. 

Out of that process, we were able to identify the top issues we believed were creating infections for our patients: unnecessary line use, delays in removal, CNA competency gaps, and documentation and visibility issues within our EHR.

Those are big cross-departmental challenges, I would imagine.

Yes, and we needed a big cross-departmental action plan if we wanted to fix them. We tasked Medisolv with helping us to create one. 

Part of that plan was actually to gather more intel through internal auditing. We needed to “secret shop” our existing processes, so to speak. We audited virtually everything we were doing around central line care. Making sure we had clear visibility on the number of lines that are active at any given time, evaluating the criteria for line necessity, evaluating our hygiene practices, and so forth. 

Some of it was very simple things like are we changing patient gowns in a timely manner? What about bed linens? Are we doing CHG baths every 24 hours? It was lots and lots of auditing.

We also needed to get every department at the same table. Medisolv helped us conduct a cross-departmental workshop where we presented our findings and our initial plan. That was critical because it gave every stakeholder a voice into the process. That was where we started to build buy-in and ownership of the issue at every level: the executive team, physicians, nursing staff, environmental services. It really helped us achieve alignment across the board.

The secret shopping is a great idea. Did that lead to any immediate changes?

Yes. For starters, our infection prevention nurses now deliver daily reports to our physicians and to the nursing leadership teams in our med-surg tower. Those reports include which patients have lines, how many days the line has been in, and the timeline for the patient’s next gown change, linen change, and CHG bath. The providers love that.

Has that triggered any changes in your EHR documentation and workflows?

Absolutely. We have a great informatics team who worked with us to turn around the changes in our central line documentation fairly quickly.  For example, we changed our hygiene intervention to be able to capture CHG baths. Through our auditing we found that those baths weren’t always being documented, so we made it easier for staff to capture it.  

What other big changes have emerged from the Zero CLABSI Committee’s action plan?

I would say the biggest change of all has been our decision to adopt a hospital-wide practice of taking zero blood draws from central line. We have an exception order for those situations where we absolutely have to draw blood from the central line, but it will be just that: the exception to the rule. It’s a huge, huge practice change for us.

Wow, that is a massive change. How has that been received?

If I’m being honest, there has been a lot of controversy. [laughs] It’s triggered a lot of disagreements, and very hard conversations needed to be had.

What was the controversy?

Our physician group was pretty much split down the middle. Fifty percent said “We’re not doing this. It won’t make a difference, so why put the patient through the discomfort of another stick?” And the other 50% said, “Yes, it does make a difference. We’re doing it.”

We had to use the influence of the doctors who were on board with us, and back up our claims with data, which included comparative data with other hospitals in our region. In the fall, we were able to put it to a vote, and it passed.

I think the key was to not force the change upon them, but to allow the debate to play out, and to use our data to guide that debate. Because in the end everyone was really just trying to figure out which policy would be the right one for our patients’ best interests.

Was it easier to get everyone else to follow the lead once your physicians were on board?

Actually, we were equally concerned about the patient response. We realized that we would be flipping the script on them, too, by telling them that we are now shifting to peripheral sticks for labs because it’s safer for them. 

So, we had a member of our patient advisory council make a video about how important it is for patient safety to not use the central line for blood draws; that this change was for the patient’s own protection. We then deployed the video across our staff in order to make sure that’s the message they deliver to our patients.

Yes, let’s talk about your staff. Because the changes you have made go beyond the new blood draw policy. As you mentioned earlier, there has been a lot that’s needed to happen around line necessity, line monitoring, and line hygiene. How are you making sure those changes remain sustainable?

We are doing a complete reset on education with every staff member that has patient contact. For example, our nursing staff and patient care techs are now required to complete a four-hour education session. If they don’t complete it, unfortunately there are disciplinary actions. That’s how seriously we take this. 

It has been about getting back to basics. Re-educating everyone and resetting the expectations of what it means to care for these patients.

If a missed CLABSI training is serious enough to warrant disciplinary action, that must mean your executive leadership is on board with what you’re trying to accomplish.

Yes, this process has truly felt like it’s given our organization a renewed focus.  We’ve done a lot of work on creating a new strategic plan, and that plan now has new short-term and long-term goals for our CLABSI work and our work to improve our star ratings. It’s a meaningful shift.

These initiatives are all so new that it’s too soon to track the change in your CLABSI rates. And of course, any changes in your star ratings are even further down the line. But have you seen any early signs of progress?

We’re seeing better awareness and better teamwork and collaboration across all disciplines. People who weren’t involved before, like our dietary staff and environmental services staff, are now one of our first lines of defense. They’re not afraid to say to a nurse, “Hey, I noticed that this patient’s bedside table wasn’t clean,” or “I’ve got your patient’s meal tray but there’s a urinal that needs to be dealt with. Would you mind taking care of it?” We didn’t always have that before.

So, what advice would you have for other quality leaders who are just starting out with a big change? How can they get to where you are?

Don’t rush to fix it yourself. Take the time, as painful as it is, to really go through the project management steps. And that means step one is getting all of your stakeholders at the table. Let them have a voice in the initiative because otherwise it’s just going to fizzle out.

I would also recommend finding a partner like Medisolv. Having outside eyes on what we’re doing and how we could do them better has been super helpful. I love them. Without them, I think we would be doing the same things we’ve always done.

Get Help With Your Hospital Star Ratings Now

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**Source: https://www.cdc.gov/infection-control/media/pdfs/Strive-CLABSI101-508.pdf

**EDITOR'S NOTE: Out of respect for client privacy, we have removed any identifying information about the hospital. We thank the hospital’s leadership team for allowing us to share their story.