Pima Medical Center is a 400-bed, multi-specialty acute-care hospital. They serve a large population of about 400,000 residents. The hospital has had a rising Hospital Acquired Infection rate (HAI) over the past four years. Primarily it has noticed a dramatic increase in Central Line Associated Bloodstream Infections (CLABSI). Pima's rate exceeds the CDC national rates of CLABSI by at least 2%. The last Joint Commission visit made an issue of this rate and the lack of mitigation strategies.

You were just promoted to a position that has oversight to address this problem. The administration has tasked you with finding the scope of the problem by comparing Pima's infection rate with other hospitals nationally, then creating a mitigation strategy. The administration wants to know what data you looked at to formulate the scope of the problem and what data you will aggregate from the hospital to reverse this issue. In addition, they want you to use Continuous Quality Improvement methodologies to suggest a strategy to fix the problem and create ongoing data to look at for purposes of monitoring.

Detail a MITIGATION STRATEGY by:

1. Suggesting new protocols on catheter insertion training, personnel, and policies.
2. Explaining what monitoring data you suggest following techniques found in Continuous Quality Improvement methods.

Please include references.