The Comprehensive Unit Based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture

Describe the CUSP intervention Delineate the five steps of CUSP Learning Objectives Describe the CUSP intervention Delineate the five steps of CUSP Discuss how CUSP can be effectively used to achieve SUSP project goals: To achieve significant reductions in surgical site infection rates and surgical complications To achieve significant improvements in safety culture

An Introduction to CUSP Part I An Introduction to CUSP

The Vision of CUSP The Comprehensive Unit-based Safety Program is designed to: Improve patient safety awareness and systems thinking at the unit level Mobilize staff to identify and resolve patient safety issues Create a patient safety partnership between executives and frontline caregivers Provide tools to help CUSP teams investigate and learn from defects and improve teamwork and safety culture

Armstrong Institute for Patient Safety and Quality CUSP or SUSP? CUSP is an Intervention to Learn from Mistakes and Improve Safety Culture SUSP is a national collaborative project to improve surgical care through TRiP and CUSP Armstrong Institute for Patient Safety and Quality

SUSP: Improving Surgical Care Through TRIP and CUSP Comprehensive Unit based Safety Program (CUSP) Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Translating Evidence Into Practice (TRiP) Summarize the evidence in a checklist Identify local barriers to implementation Measure performance Ensure all patients get the evidence Engage Educate Execute Evaluate Reducing Surgical Site Infections ** Emerging Evidence Local Opportunities to Improve Collaborative learning ** and other surgical complications Adaptive Work Technical Work http://www.hopkinsmedicine.org/armstrong_institute

Pre-SUSP Work Create a SUSP team Nurse, physician, administrator, others Imperative for frontline staff to be involved Measure culture in the unit (Hospital Survey of Patient Safety “HSOPS”) Work with hospital quality leader or hospital management to recruit a senior executive as an active member of the SUSP team Start in one area or service line (i.e., colon surgery), and then spread to others

Educate everyone in the Science of Safety 2. Identify defects CUSP Steps Educate everyone in the Science of Safety 2. Identify defects 3. Recruit executive as active SUSP team member 4. Learn from one defect per quarter Implement teamwork tools Timmel, et al. 2010.

A ‘walk through’ of the CUSP process Part II A ‘walk through’ of the CUSP process

Step 1: Educate Everyone in the Science of Safety Understand that the system determines performance Use strategies to improve system performance Standardize work to reduce complexity Create independent checks for key processes Learn for mistakes Apply strategies to both technical work and team work Recognize teams make wise decisions with diverse and independent input

Strategies for Educating on the Science of Safety Unit level staff meetings Medical staff grand rounds Hospital/unit orientation Continuous access via in-house TV / training Posting on intranets or other training sites

Step 2: Identify Defects 2 Question Staff Safety Assessment: How is the next patient likely to be harmed on our unit? What do you think we could do to prevent that harm? Review error reports, liability claims, sentinel events or M and M conference

Tap Into Staff Wisdom: How Will the Next Patient be Harmed? Percent age of Responses (%) 148 answers from 51 staff members Schwengel, et al. 2011.

How will the next patient be harmed? (SSI Specific) 95 Responses from 36 Staff Members Percentage of Responses (%) Wick, et al. 2012.

Step 3: Recruit Executive as Active SUSP Team Member Executive meets at least monthly with team Review defects identified on staff safety assessment Work with team and develop plan to reduce risks Ensure team has resources to implement plan Shared accountability during monthly review of: Action plans; infection data; resource allocations HSOPS (culture) data Staff Safety Assessment data

Step 4: Learning from Defects Select a specific defect and use LFD tool to explore: What happened? Why did it happen? (Use system lenses from science of safety.) What could you do to reduce risk ? How do you know risk was reduced ? Create early wins for the project Berenholtz, et al. 2009. Pronovost, et al. 2006.

Identifying Safety Issues and Opportunities for Improvement CUSP Step 2: Safety Issue Identified CUSP Steps 4 & 5: Opportunities to improve Infection Control Skin preparation Hypothermia Contamination of bowel contents into the wound Antibiotic timing Selection and redosing Length of case Coordination of Care Increase utilization of preoperative evaluation center, Improve surgical posting accuracy (case name and duration) Computer assistance for antibiotic selection and redosing Communication and Teamwork Improve communication throughout perioperative period Empower team members to speak up Improve compliance with briefings/debriefings Implement teamwork tools Equipment/ Supplies Accurate temperature probes Point of care glucose monitoring Under body warmers Sanitizing wipes near anesthesia machine Policies/Protocols Standardize care/protocols/policies Monitor sterile technique policies Education/Training Ongoing education (with supportive data) Development of a SSI prevention checklist Wick, et al. 2012.

Step 5: Implement Teamwork Tools Briefing and Debriefings Specific TeamSTEPPS® Teamwork Tools Morning Briefing / Huddle Handoff Tools Barrier Identification and Mitigation (BIM) Tool Learning from Defects Shadowing Safety Culture Debriefing

Why Briefings and Debriefings Matter Reductions in communication breakdowns and OR delays 1 Reductions in procedure and miscommunication-related disruptions and nursing time spent in core 2 Improved communication and teamwork, feasible given current workload 3 Reductions in rate of any complications, SSI and mortality 4 1 Nundy, et al. 2008. 2 Henrickson, et al. 2009. 3 Berenholtz, et al. 2009. 4 Haynes, et al. 2009.

It Takes Culture Change to Get the Most Out of Checklists Culture change is critical to improving briefings and debriefings Example: WHO Surgical Safety Checklist Significant reductions in mortality and morbidity 50% of reductions were associated with the amount of culture change in the sites Think beyond the checklist! Haynes, et al., 2009

Wrong-Patient, Wrong-Site, Wrong-Procedure Events The Joint Commission, Sentinel Event Data; http://www.jointcommission.org/assets/1/18/Event_Type_Year_1995-2011.pdf;29.

Armstrong Institute for Patient Safety and Quality Michigan CUSP Results   “Needs Improvement”: Less than 60% of respondents reporting good safety or teamwork climate Statewide in 2004, 82-84% needed improvement, in 2007 22-23% Pronovost, et al. 2008. Sexton, et al. 2011 Armstrong Institute for Patient Safety and Quality

Most effective when coupled with TRiP CUSP Lessons Learned Culture is local Implement in a few units, adapt and spread Include frontline staff on improvement team Not a linear process Iterative cycles Culture change is a long-term journey (it takes time to improve) Most effective when coupled with TRiP Opportunity to practice CUSP tools Engages frontline providers CUSP alone viewed as ‘soft’

Next Steps Ensure SUSP team members who could not attend this call access archived materials at the Armstrong Institute (AI) website http://www.hopkinsmedicine.org/quality_safety_research_group/our _projects/action_II/SUSP/ Continue to form your team with an appreciation of the importance of WHO is on the team Complete the SUSP team membership form (available at the AI website) Identify key missing players/roles Think about how you will: Train everyone in the science of safety Identify hazards Recruit and engage an executive as active CUSP team member 24

On-boarding Call Evaluation We want to ensure that the on-boarding calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link: https://www.research.net/s/susp_cohort_3 If you are not able to reach the link from the slide, please cut & past the URL into your browser. Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality References Slide 8: Timmel J, Kent PS, Holzmueller CG, Paine LA, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf. 2010;36:252-60. Slide 13: Schwengel DA, Winters BD, Berkow LC, Mark L, Heitmiller ES, Berenholtz SM. A novel approach to implementation of quality and safety Programs in anesthesiology. Best Pract Res Clin Anaesthesiol. 2011 Dec;25(4):557-67. Slide 14: Wick EC, Hobson D, Bennett J, Demski R, Maragakis L, Gearhart SL, et al. Implementation of a surgical Comprehensive Unit Based Safety Program (CUSP) to reduce surgical site infections. J Am Coll Surg. 2012 May 23. [Epub ahead of print] Slide 16: Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From defects to enhance morbidity and mortality conferences. Am J Med Qual. 2009;24(3):192-5. Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Saf. 2006;32:102-108. Slide 17 : Wick EC, Hobson D, Bennett J, Demski R, Maragakis L, Gearhart SL, et al. Implementation of a surgical Comprehensive Unit Based Safety Program (CUSP) to reduce surgical site infections. J Am Coll Surg. 2012 May 23. [Epub ahead of print] Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality References Slide 19: Nundy S, Mukherjee A, Sexton JB, Pronovost PJ, et al. Impact of preoperative briefings on operating room delays: A preliminary report. Arch Surg. 2008;143(11): 1068-1072. Henrickson SE, Wadhera RK, ElBardissi AW, Wiegmann DA, Sundt TM. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009;208:1115–1123. Berenholtz SM, Schumacher K, Hayanga AJ, et al. Implementing standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf. 2009;35:391-397. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009; 360:491-499. Slide 20: Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360:491-499. Slide 22: Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23:207-221. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of ICUs. Crit Care Med. 2011;39(5):1-6. Armstrong Institute for Patient Safety and Quality