4
Models and Frameworks Tables
Table 2. The 4Es
• Well-suited for large-scale projects and projects that include multiple sites
• Helps teams to partner in the implementation process (hospital leaders, improvement
team leaders, frontline staff )
• Cyclical nature allows for feedback to drive modifications and adaptations
• Provides a guide for resolving knowledge gaps through education
• Associated with interventions that resulted in reductions in HAIs, mortality, and
costs, when paired with efforts to improve safety culture
7
• Does not include targeted strategies to address multilevel barriers that may hinder
implementation
4Es strategies
1
:
1. Engagement: To motivate key working partners to take ownership and support the
proposed interventions.
2. Education: To ensure key working partners understand why the proposed
interventions are important.
3. Execution: To embed the intervention into standardized care processes.
4. Evaluation: To understand whether the intervention is successful.
Settings that have applied the 4Es:
• Healthcare facilities
• Large-scale projects with multiple sites
Improvements using the 4Es:
• CLABSI prevention
2, 4
• CAUTI prevention
3
• Mortality reduction
5
• Cost savings
6
1. Pronovost, PJ, Berenholtz, SM, Needham, DM. Translating evidence into practice: a model for
large scale knowledge translation. BMJ 2008;337:a1714
2. Berenholtz, SM, Lubomski, LH, Weeks, K, et al. Eliminating central-line–associated bloodstream
infections: a national patient safety imperative. Infect Control Hosp Epidemiol 2014;35:56–62.
3. Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related
bloodstream infections in the ICU. N Engl J Med 2006;355:2725–2732.
4. Pronovost, PJ, Watson, SR, Goeschel, CA, Hyzy, RC, Berenholtz, SM. Sustaining reductions
in central-line–associated bloodstream infections in Michigan intensive care units: a 10-year
analysis. Am J Med Qual 2016;31:197–202.
5. Lipitz-Snyderman, A, Steinwachs, D, Needham, DM, Colantuoni, E, Morlock, LL, Pronovost, PJ.
Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and
length of stay: retrospective comparative analysis. BMJ 2011;342:d219)
6. Waters, HR, Korn, R Jr, Colantuoni, E, et al. The business case for quality: economic analysis of
the Michigan Keystone Patient Safety Program in ICUs. Am J Med Qual 2011;26:333–339.
7. Sexton, JB, Berenholtz, SM, Goeschel, CA, et al. Assessing and improving safety climate in a large
cohort of intensive care units. Crit Care Med 2011;39:934–939.
