An Intervention to Learn from Mistakes and Improve Safety Culture On the CUSP: STOP BSI The Comprehensive Unit-based Safety Program (CUSP): An Intervention to Learn from Mistakes and Improve Safety Culture BNVBBVB

Immersion Call Overview Week 1: Project overview Week 2: Science of Improving Patient Safety Week 3: Eliminating CLABSI Week 4: The Comprehensive Unit-Based Safety Program (CUSP) Week 5: Building a Team Week 6: Physician Engagement

The CUSP/ CLABSI Intervention 1. Educate staff on science of safety 2. Identify defects 3. Assign executive to adopt unit 4. Learn from one defect per quarter 5. Implement teamwork tools CLABSI Remove Unnecessary Lines Wash Hands Prior to Procedure Use Maximal Barrier Precautions Clean Skin with Chlorhexidine Avoid Femoral Lines

Learning Objectives To explain the philosophy and approach of CUSP To describe the steps in CUSP To introduce available teamwork tools

What is CUSP? Comprehensive Unit-based Safety Program An Intervention to Learn from Mistakes and Improve Safety Culture

On the CUSP: Stop BSI Intervention Comprehensive Unit-based Safety Program (CUSP) -Improve or reinforce good cross-disciplinary communication and teamwork -Enhance coordination of care -Address overall patient safety -Work towards healthy unit culture BSI-Reduction Protocol -Best-evidence supplies, organization of supplies Ensuring all patients receive the best practices -Checklist to ensure consistent application of evidence The intervention consists of two parts that you will pursue simultaneously. So while you are doing the work of reducing BSI, you will also be seeking to improve communication among care team members, finding ways to better coordinate care, improving overall patient safety on your unit and working toward a healthy and rewarding unit culture. Today’s presentation is about the left side of this graphic, the CUSP program, the purpose of which is to help you realize these goals, by tailoring its tools to your own unit and situation.

Safety Score Card Keystone ICU Safety Dashboard   2004 2006 How often did we harm (BSI) (median) 2.8/1000 How often do we do what we should 66% 95% How often did we learn from mistakes* 100s Have we created a safe culture What areas need improvement (%) Safety climate* 84% 43% Teamwork climate* 82% 42% Returning CAUTION: note that culture items are in terms of NEEDING IMPROVEMENT * CUSP is intervention to improve these

Pre CUSP Work Create a CUSP/CLABSI team Measure culture in the unit Nurse, physician administrator, others Assign a team leader Measure culture in the unit Work with hospital quality leader or hospital management to have a senior executive assigned to CUSP/CLABSI team Discuss culture measurement with hospital association leader (how, what instrument, when)

Steps of CUSP Educate staff on Science of Safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools The intervention we used to improve culture and learn from mistakes is the Comprehensive unit based safety program. Pronovost J, Patient Safety, 2005

Step 1: Science of Safety Understand system determines performance Use strategies to improve system performance Standardize Create independent checks for key process Learn from mistakes Apply strategies to both technical work and team work Recognize teams make wise decisions with diverse and independent input I have found that there are three key components to understanding the science of safety Understand that the system determines performance.

Step 2: Identify Defects Review error reports, liability claims, sentinel events or M and M conference Ask staff how will the next patient be harmed

Prioritize Defects List all defects Discuss with staff what are the three greatest risks

Step 3: Executive Partnership Executive should become a member of ICU team Executive should meet monthly with ICU team Executive should review defects, ensure ICU team has resources to reduce risks, and hold team accountable for improving risks and central line associated blood steam infection

Step 4: Learning from Mistakes What happened? Why did it happen (system lenses) ? What could you do to reduce risk ? How do you know risk was reduced ? Create policy / process / procedure Ensure staff know policy Evaluate if policy is used correctly Pronovost 2005 JCJQI

Step 4 cont’d: Identify Most Important Contributing Factors Rate each contributing factor importance of the problem and contributing factors in causing the accident importance of the problem and contributing factors in future accidents

Step 4 cont’d: Identify Most Effective Interventions Rate Each Intervention How well the intervention solves the problem or mitigates the contributing factors for the accident Rates the team belief that the intervention will be implemented and executed as intended

Step 4 cont’d: Evaluate Whether Risks were Reduced Did you create a policy or procedure Do staff know about the policy Are staff using it as intended Do staff believe risks have been reduced

Step 5: Teamwork Tools Call list Daily goals AM briefing Shadowing Culture check up Step 5 of CUSP is to address interdisciplinary communication and teamwork by implementing tools designed to address these issues. You may also have your own ideas about how to improve communication and teamwork. Here we discuss 5 of the tools we developed, and modify to make useful in your own setting. Pronovost JCC, JCJQI

Step 5 cont’d: Call List Ensure your ICU has a process to identify what physician to page or call for each patient Make sure call list is easily accessible and updated

Step 5 cont’d: AM Briefing Have a morning meeting with charge nurse and unit attending(s) about the unit-level plan for the day Discuss work for the day What happened during the evening Who is being admitted and discharged today What are potential risks during the day, how can we reduce these risks

Step 5 cont’d: Shadowing Follow another type of clinician doing his or her job for between 2 to 4 hours Have the shadower discuss with staff what she will do differently now that she has walked in another person’s shoes

CUSP is a Continuous Effort Add Science of Safety education to orientation Learn from one defect per quarter, share or post lessons Implement teamwork tools that best meet the unit’s needs Details are in the CUSP manual

Action Items--CUSP Look over the CUSP manual with team members Brainstorm potential hazards with team Assess team composition with respect to CUSP elements REVIEW PRE-IMPLEMENTATION CHECKLIST—where are you?

References Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003; 18(2):71-75. Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68. Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):476-479.