Total Quality Management, Journey To Excellence, Continuous Quality/Process Improvement, And Ethical Issues

Urinary tract infections (UTIs) are more susceptible in patients that have an indwelling catheter for longer periods of time, versus patients with short-time use (Letica-Kriegel et al., 2019). For this reason, the Center for Medicare and Medicaid Services (CMS) added Catheter-Associated Urinary Tract Infection (CAUTI) to their list of health care-acquired conditions (HACs), and so that hospitals create risk management strategies to prevent this from happening in patients (CMS, 2021).

Henry Ford Allegiance Health has implemented a policy titled, “Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) to ensure that indwelling urinary catheters are only left in place as long as medically necessary, strict maintenance of the catheter is followed, and indwelling catheterization should be avoided if other means are available and appropriate (HFAH, 2021). This policy is to be used by physicians and nursing staff, as well as families and patients that are educated in the insertion of or in the care of catheter use (HFAH, 2021). It covers the different kinds of catheterization available and indications for catheter use, as well as maintenance of and urine collection of urinary catheters and can be accessed via the policy portal on the OneHenry website. If a patient were to be diagnosed with a UTI while having a urinary catheter, this would be reported using the RL reporting process and looked into to understand what/where/when/why this was caused and how it could have been prevented. Overtime, this information can be used to amend the policies as necessary to improve prevention.

In my experience, I utilize this policy any time that we have a patient on the unit that utilizes any form of urinary catheterization. On our mental health unit, we can go weeks or months without coming across any form of urinary catheter, so when we do… it is important to refer to the policy to avoid CAUTI in our patients.

The Center for Medicare and Medicaid Services (CMS) publishes a list of health care-acquired conditions (HACs) that reasonably could have been prevented through the application of risk management strategies. What actions has your health care organization (or have health care organizations in general) implemented to manage or prevent these “never events” from happening within their health care facilities? Support your response with a minimum two peer-reviewed articles.


Using 200-300 words APA format with at least two references. Sources must be published within the last 5 years. There should be a mix between research and your reflections. Add critical thinking in the posts along with research. Apply the material in a substantial way.