Healthcare-associated infections (HAIs) are a leading cause of morbidity and mortality in the U.S. The move to eliminate HAIs has been slow and reports of individual successes have been dwarfed by the number of programs that witnessed initial success, yet have experienced challenges with sustainment. This has been attributed to the lack of theory-based frameworks that describe and evaluate the relationships within infection prevention programs. The purpose of this study was to test a

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... e theoretical model to identify and explain the relationships between the concepts of adherence to HAI prevention interventions, organizational context, and HAI outcomes using structural equation modeling (SEM). The Quality Health Outcomes Model (QHOM) guided the study. Methods: Measures to represent the latent variables of adherence to central lineassociated bloodstream infection (CLABSI) prevention interventions, organizational context, and CLABSI outcomes were selected for this secondary analysis from 614 hospitals that participated in the Prevention of Nosocomial Infection and Costeffectiveness -Refined dataset, a large national survey of infection prevention and control programs. One-half of the dataset was used for exploration of the concepts, the second half for confirmation of the model. iv Results: SEM indicated support for the proposed middle-range theoretical model, for the model fit the data well. The relationship between adherence to CLABSI interventions and organizational context was confirmed. The relationship between organizational context and CLABSI outcomes was not statistically significant. The construct validity of three instruments that represent the concepts of the work environment, organizational climate, and CLABSI interventions were confirmed. Lastly, organizational context was confirmed as a second-order model. Conclusions: The results support the conceptual model, based on the QHOM, as applied to infection prevention in hospitals. The study highlighted the complexity of measuring organizational context and exposed weaknesses in the measurement and reporting of HAI outcomes as a patient safety indicator. The findings suggest that patient safety programs may have a greater impact if they focus on an organizational context that facilitates high-levels of adherence to infection prevention interventions over reporting adverse outcomes. The form and content of this abstract are approved. I recommend its publication. Approved: Karen H. Sousa v DEDICATION To my parents, who have been my sources of strength and inspiration since the very beginning. To my husband, this is as much your achievement as it is mine. To my two boys, may this remind you that anything is possible. Thank you all for your support, love and constant reminders of what is truly important. vi ACKNOWLEDGMENTS Many thanks go to my advisor, Karen Sousa, for her gentle guidance over the past four years. This work is a testament to her passion for nursing research and her skills as a mentor, statistician, and systems researcher. I am grateful for the members of my committee: