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Implementation of a Clostridioides difficile prevention bundle: Understanding common, unique, and conflicting work system barriers and facilitators for subprocess design

  • Jackson S. Musuuza (a1) (a2), Ann Schoofs Hundt (a3), Pascale Carayon (a3) (a4), Karly Christensen (a5), Caitlyn Ngam (a5), Nicholas Haun (a1) (a2) and Nasia Safdar (a1) (a2)...



Clostridioides difficile (C. difficile) poses a major challenge to the healthcare system. We assessed factors that should be considered when designing subprocesses of a C. difficile infection (CDI) prevention bundle.


Phenomenological qualitative study.


We conducted 3 focus groups of environmental services (EVS) staff, physicians, and nurses to assess their perspectives on a CDI prevention bundle. We used the Systems Engineering Initiative for Patient Safety (SEIPS) model to examine 5 subprocesses of the CDI bundle: diagnostic testing, empiric isolation, contact isolation, hand hygiene, and environmental disinfection. We coded transcripts to the 5 SEIPS elements and ensured scientific rigor. We sought to determine common, unique, and conflicting factors across stakeholder groups and subprocesses of the CDI bundle.


Each focus group lasted 1.5 hours on average. Common work-system barriers included inconsistencies in knowledge and practice of CDI management procedures; increased workload; poor setup of aspects of the physical environment (eg, inconvenient location of sinks); and inconsistencies in CDI documentation. Unique barriers and facilitators were related to specific activities performed by the stakeholder group. For instance, algorithmic approaches used by physicians facilitated timely diagnosis of CDI. Conflicting barriers or facilitators were related to opposing objectives; for example, clinicians needed rapid placement of a patient in a room while EVS staff needed time to disinfect the room.


A systems engineering approach can help to holistically identify factors that influence successful implementation of subprocesses of infection prevention bundles.


Corresponding author

Author for correspondence: Nasia Safdar, Email:


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