Comprehensive Unit-based Safety Program (CUSP) Teré Dickson, MD, MPH HAI Webinar April 9, 2012

CMS  Leads a national healthcare quality improvement program, implemented locally by an independent network of QIOs in each state and territory. IPRO  The federally funded Medicare Quality Improvement Organization (QIO) for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS). 2

The QIO Program  Largest federal program dedicated to improving health quality at the local level,  Trustworthy partners for the continual improvement of healthcare for all Americans,  Focuses on three broad aims:  Better patient care,  Better population health,  Lower healthcare costs through improvement. 3

As the QIO for New York State, IPRO works to achieve the goals of the national QIO program by  Convening communities of providers, practitioners and patients across the state to:  Share knowledge,  Spread best practices,  Achieve rapid, wide-scale improvements in patient care. 4

The QIO Program supports patients by:  Providing information to help you better manage your own healthcare,  Reviewing quality of care complaints,  Working with local healthcare providers to make healthcare safer and “patient-centered,”  Listening to you and learning from your experiences,  Helping to remove roadblocks between you and better healthcare. 5

The QIO Program supports providers by:  Managing and sharing evidence-based best practices, knowledge and tools for improving health quality, efficiency and value.  Serving as a change agent for rapid, widespread and significant improvements that contribute to broader national healthcare goals.  Facilitating collaborative learning and action that results in better, more patient-centered care.  Encouraging beneficiaries to take a more active role in their own healthcare. 6

QIO Program Priorities  Beneficiary- and Family-Centered Care  Improving Individual Patient Care by Reducing  Healthcare-Associated Infections in Hospitals  Healthcare-Acquired Conditions in Nursing Homes  Adverse Drug Event  and through Quality Reporting  Integrating Care for Populations and Communities  Improving Health for Populations and Communities 7

Today’s Webinar: CUSP Town Hall Meeting A town hall meeting is an informal public meeting which gives the members of a community an opportunity to get together to discuss emerging issues and to voice concerns and preferences for their community

Interact with us!  Operator assisted call  Chat box  To the group  To the moderator  When you respond or comment, please say your name and hospital. 9

Special Guests – St. John’s Episcopal Hospital St. John’s Episcopal Hospital is the only full service community hospital serving the entire Rockaway and the Five Towns communities providing general adult medical surgical services, pediatrics, obstetrics and psychiatric services.  Initiated CUSP in January 2010  Gail Johnson  Nancy Traver 10

Poll Question 1 My hospital has started using CUSP to address CLABSIs and CAUTIs.  Yes  No 11

Poll Question 2 My hospital has considered using CUSP, but either decided against it or doesn’t know how to get started.  Yes  No 12

Poll Question 3 My hospital has an alternative to CUSP in place, such as the use of brainstorming teams, multidisciplinary patient safety rounds with hospital administration, feedback to unit staff on infection rates and targets, educational sessions for unit staff, and/or application of root cause analysis to investigate infections.  Yes  No 13

Principles of CUSP  Understand system determines performance and results.  Use strategies to improve system performance.  Apply strategies to both technical work and team work.  Recognize teams make wise decisions with diverse and independent input. 14

Five Steps of CUSP 1. Educate staff on the science of safety 2. Identify defects 3. Assign executive to adopt unit 4. Learn from one defect per quarter 5. Implement teamwork tools 15

The 4E’s to CUSP Success  Engage  Storytelling, Press releases, Share data  Educate staff on evidence  Execute  Standardize  Create independent checks  Empower nursing  Learn from mistakes  Evaluate  Performance and progress feedback 16

Keep It Simple CUSP  Learn from 1 defect per desired time period  Collaboration  Consolidation  Sustainability 17

CUSP In-depth On The CUSP: Stop HAI 18

The St. John’s Episcopal Hospital CUSP Experience 19

Choosing CUSP Driving Forces  High CLABSI Rate  MICU: 2.6/1000 device days in 2010 with a national mean of 1.9  Hospital Administrator - Sharon Behar, VP for Regulatory Affairs  HANYS and national On the CUSP initiative 20

Pre-CUSP Activities  Web Conferences  Team Formation  Administrative Champion  Infection Control Committee Chairman  Physician Champion  Nursing Champion (VP of Patient Care Services)  Infection Preventionist  Data Collection  AHRQ Hospital Survey on Patient Safety  Trained staff on Science of Safety 21

CUSP Processes for CLABSI Prevention  Removal of the defects that lead to central line related bacteremia  Understanding the complexity involved to creating a plan to reduce errors  Putting all equipment needed for insertion in one place and/or pkg  Residents must notify nurse who will assist with insertion  Insertion checklist to empower nurses to document deviations  Observing Rounds  AM and PM Briefing  Daily Goals Checklist 22

CUSP Intervention - Peer Review  Developed the peer review form to assess the compliance with all strategies and bundles.  The night shift monitors the day shift on care for patients with lines and vice versa. 23

CUSP Results MICU had a rate of 2.6/1000 device days in 2010 with a national mean of 1.9  2011: the rate had dropped to 1.5 below the national mean of 1.6 Feedback to Staff  CUSP Boards where infection rates were posted monthly  Fun Competition 24

CUSP Sustainability and Expansion After about 6 months, noticed modest gains in monthly rate reduction  Decided to host more CUSP trainings with video about Josey King At 9 months – CUSP went housewide! (Med Surg and Pulmonary floors)  Recruited different physician champions and unit/floor champions with same administrative champion  Champions brought others on board with roll-out and were instrumental in CUSP success 25

Townhall Discussion  Data resources used  Education tactics – Science of Safety and CUSP directed initiatives  Engagement tactics – Executive and front line staff  Team member selection and team building  Scheduling concerns – consolidate with other meetings vs separate timing  Investigations of defects  Feedback methods  Sustainability 26

Townhall Discussion What is your hospital doing as an alternative to CUSP? 27

Feedback on CUSP Trainings and Resources  Fall LAN Meeting  AHRQ/HRET National Webinar on CUSP   Quarterly Newsletters – CUSP Corner  Today’s Webinar/Townhall 28

This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM

For more information Teré Dickson, MD, MPH Medical Officer (516) IPRO CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY IPRO REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY Template 1/13/2012