1. 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

2. 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

3. 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

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

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

6. 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.

7. 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

8. 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)

9. 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

10. 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.

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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?

24. 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):