The Comprehensive Unit Based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture Paula Kent, MSN, MBA September 11, 2012 Armstrong Institute for Patient Safety and Quality Conference Number(s):800-779-9891 Participant Code:4757941

On Boarding Call Schedule Program Introduction Building Your CUSP Team Science of Safety –September 4, 2012 @2:00pm CUSP - September 11, 2012 @2:00pm VAP Evidence- September 18,2012 @ 2:00pm Daily Goal Review -September 25, 2012 @ 2:00pm

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 CUSP for VAP:EVAP project goals: To achieve significant reductions in VAP rates and complications related to mechanical ventilation 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 vs. VAP? CUSP is an Intervention to Learn from Mistakes and Improve Safety Culture CUSP is the safety foundation that supports the efforts to reduce VAP rates by translating evidence into practice (TRiP) Armstrong Institute for Patient Safety and Quality

The Armstrong Institute Model to Improve Care Comprehensive Unit based Safety Program (CUSP) Educate staff on science of safety Identify defects Recruit executive to adopt unit Learn from one defect per quarter Implement teamwork tools Translating Evidence Into Practice (TRiP) Summarize the evidence Identify local barriers to implementation Measure performance Ensure all patients get the evidence Engage Educate Execute Evaluate Eliminating Ventilator Associated Pneumonia Emerging Evidence Local Opportunities to Improve Collaborative learning http://www.hopkinsmedicine.org/armstrong_institute Technical Work Adaptive Work

Pre-CUSP Work Create a CUSP team Nurse, physician, administrator, respiratory therapist, 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 CUSP team

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 CUSP 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 from 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 Two-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 Reference: Schwengel, et al. 2011.

Step 3: Recruit Executive as Active CUSP 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 Wick et al. 2012

Step 4: Learning from Defects (LFD) 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 (“go after the low hanging fruit”) Berenholtz, et al. 2009. Pronovost, et al. 2006.

Learning from Defects and VAP There are systems defects that contribute to the incidence of VAP. Many of these are related to the implementation of VAP prevention processes. Learning from defects analysis can help identify where the systems that should support these processes fall short.

VAP Prevention Processes: Opportunities for Improvement Head of Bed Elevation (HOB) Use of a semi-recumbent position ( ≥ 30 degrees). Spontaneous Awakening and Breathing Trials (SAT & SBT) Daily assessment of sedation and readiness to wean Oral Care At least 6 times per day Oral Care with Chlorhexidine (CHG) Should be included in the oral care regimen 2 times per day Subglottic Suctioning Endotracheal Tubes (ETTs) Use subglottic suctioning ETTs in patients expected to be mechanically ventilated for >72 hours Wick et al. 2012.

Opportunities for Improvement: Policy-Based Structural Measures Use a closed ETT suctioning system Change close suctioning catheters only as needed Change ventilator circuits only if damaged or soiled Change HME every 5-7 days and as clinically indicated ETT endotrachael tube; HME heat moist exchanger

Use early mobility protocol Opportunities for Improvement: Policy-Based Structural Measures, cont’d Provide easy access to NIVV equipment and institute protocols to promote use Periodically remove condensate from circuits, keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient Use early mobility protocol NIVV non-invasive ventilation Nundy et al. 2008 Henrickson et al. 2009 Berenholtz et al. 2009 Haynes et al. 2009

Opportunities for Improvement: Policy-Based Structural Measures, cont’d. Perform hand hygiene Avoid supine position Use standard precautions while suctioning respiratory tract secretions Use orotracheal intubation instead of nasotracheal Avoid use of prophylactic systemic antimicrobials Avoid non-essential tracheal suctioning Avoid gastric over-distention

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

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

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

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’

Action Items Ensure CUSP 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 CUSP team membership form (available from your hospital association) 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 26

Complete and submit the commitment/enrollment forms Finalize enrollment Complete and submit the commitment/enrollment forms Questions or comments: Karol G. Wicker, MHS Senior Director, Quality Policy & Advocacy Maryland Hospital Association kwicker@mhaonline.org Mary Catanzaro RN BSMT CIC Project Manager HAIs Hospital and Healthsystem Association of Pennsylvania mcatanzaro@haponline.org

References Slide 5: http://www.hopkinsmedicine.org/armstrong_institute Accessed September 17th 2012. Slide 9: 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 14: 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 15: 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 18: 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 References Slides 19 - 20: 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 23: 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 24: 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