1. On the CUSP: STOP BSI Overview of STOP-BSI Program
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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. Learning Objectives To delineate the goals of STOP-BSI
To describe the project organization
To define the interventions
To outline the planned learning sessions
To identify who to call for help

5. On the CUSP: STOP BSI Goals
To work to eliminate central line associated blood stream infections (CLABSI): reaching state means
less than 1/1000 catheter days, state median 0
To improve safety culture by 50%
To learn from one defect per quarter

6. Have We Created a Safe Culture?
Measure
Have We Created a Safe Culture?
How Do We know We Learn
from Mistakes?
How Often Do we Harm?
Are Patient Outcomes
Improving?
CUSP
Comprehensive Unit based Safety program
Educate staff on science of safety
Identify defects
Assign executive to adopt unit
Learn from one defect per quarter
Implement teamwork tools
(TRiP)
Translating Evidence Into Practice
Summarize the evidence in a checklist
Identify local barriers to implementation
Measure performance
Ensure all patients get the evidence
This is our Hopkins model for improvement that includes CUSP to improve teamwork and communication and TRiP to focus on specific evidence-based clinical challenges. CUSP is agnostic to clinical issue; TRiP is very specific. Learning from Defects happens at a unit level. LFD discussions happen monthly but we know that some defects take more than a month to resolve. Thus, we expect teams to complete an LFD cycle no less than quarterly.
IMPROVE

7. 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

8. 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
% Needs improvement in
Safety climate*
84%
43%
Teamwork climate*
82%
42%
The scorecard is designed to report as rate based measures only those interventions that can be validly measured as rates. In the Keystone Project, we had rates for CLABSI and rates for VAP processes of care (how often do we do what we should?).
In the scorecard, we also captured important improvements that can’t be measured as rates. Though we would love to understand how well and how often teams learn from mistakes, there is no way to quantify that. We say hundreds to acknowledge that once teams develop a lens to see patient safety issues, learning from mistakes becomes a unit norm. The LFD form is used to quantify significant or common mistakes but on a daily basis many units find a way to capture and record mistakes and how they’ve been resolved.
In Keystone ICU, we were able to quantify the rate of culture improvement using the SAQ scores. In this national project, we will be using HSOPS to assess improvements in culture (teamwork and communication).
Finally, you likely notice that the first two items on the scorecard, relate to measures on TRiP and the second two items reflect components or interventions that are part of CUSP.
CUSP is an intervention to improve these*

9. Project Organization
State-wide effort coordinated by Hospital Association or designated collaborative agency
Learning collaborative model (e.g., multisite participation, 2 face-to-face meetings, monthly calls)
Standardized data collection tools and evidence
Local unit modification of how to implement interventions

10. Staff Identify Defects
On The CUSP
Stop BSI
Technical CLABSI
CVC Insertion
CVC Line Cart
1. Contents inventory
Evidence based BSI prevention (hands, site, skin prep, barrier, removal)
1. Presentation of evidence
2. CLABSI factsheet
3. Insertion checklist
4. Vascular access quiz
5. Vascular access manual/ policy 6.Annotated bibliography
CVC Management
1. Daily goals
2. Dressing change
3. Vascular access manual/ policy protocol
Adaptive (CUSP)
Science of Safety Training
1. Science of safety presentation
3. Attendance sheet
Staff Identify Defects
1. Staff safety assessment form
2. Indentifying hazards presentation
Senior Executive Partnership
Briefings
Learning from Defects
LFD toolkit
Implement Tools for Teamwork and Communication
2. Shadowing
3. AM briefing
4. Call list
6. Team check up tool
Assemble a CUSP team,
Partner with a senior executive;
Baseline Data
Exposure Survey and Technology Survey
Culture Survey
This is the basic relationship structure of the project. Emphasize that this is a work in progress. Hopkins continues to create and update tools and it will continue to be modified. 20

11. Intervention to Eliminate CLABSI

12. Pronovost, Berenholtz, Needham BMJ 2008
Identifying the 5 steps to eliminate CLABSI represents the culmination of a labor-intense and rigorous process to move from evidence to interventions that are feasible at the bed-side.
Pronovost, Berenholtz, Needham BMJ 2008

13. Evidence-based Behaviors to Prevent CLABSI
Remove unnecessary lines
Wash hands prior to procedure
Use maximal barrier precautions
Clean skin with chlorhexidine
Avoid femoral lines
I want to highlight 5 strategies specifically because they are well supported by the evidence. Central lines should be discontinued when they are no longer needed. Strict compliance with hand washing is essential. We should use maximal barrier precautions during cl insertion, We should use chlor for skin preparation if the patient is not allergic, and if we have a choice, subclavian sites are preferred over internal jugular or femoral sites.
The benefit of removing central lines when they are no longer needed is self-explanatory . One point that I would ask you to consider though is whether you have a mechanism in place to assess the need for central access for your patients on a daily basis. If not, you need to develop one.
MMWR. 2002;51:RR-10

14. Identify Barriers Ask staff about knowledge
Ask staff what is difficult about doing these behaviors
Walk the process of staff placing a central line
Observe staff placing central line
Ways to identify barriers are suggestions and it might be helpful to have different people from your unit to participate in these states. For example, ask the infection preventionist observe the process of placing a central line and separately ask a staff nurse to do the same thing. Invite the two individuals to compare notes and discuss what they saw. Each of us has unique lenses with which we see the work and there is much to be learned by inviting people to share perspectives.

15. Ensure Patients Reliably Receive Evidence
Senior
Team
Staff
leaders
Engage
How does this make the world a better place?
Educate
What do we need to do?
Execute
What keeps me from doing it?
How can we do it with my resources and culture?
Evaluate
How do we know we improved safety?
This is the model we used for leading change. It recognizes the technical (science) part and the adaptive (emotional/attitudes/ behavioral part).
Engaging people is adaptive work done locally by telling stories and showing current evidence of harm.
Educate is technical. What is the evidence?
Execute is adaptive and local. Given my resources, how do I ensure all patients reliably receive the evidence.
Evaluate is technical. We have to measure in a scientifically sound way
Pronovost: Health Services Research 2006

16. Ideas for Ensuring Patients Receive the Interventions: the 4Es
Engage: stories, show baseline data
Educate staff on evidence
Execute
Standardize: Create line cart
Create independent checks: Create BSI checklist
Empower nurses to stop takeoff
Learn from mistakes
Evaluate
Feed back performance
View infections as defects
Feedback performance many ICUs posted graphs of number of weeks without infection

17. Comprehensive Unit-based Safety Program (CUSP)

18. Pre CUSP Work Create a unit-level team Measure culture in the unit
Nurse, physician administrator, others
Assign a team leader
Measure culture in the unit
Seek out a senior executive to participate on unit-level team

19. CUSP Elements 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.
Tell some of the defects that surface during CUSP work.
Pronovost J, Patient Safety, 2005

20. We are on a Continuous Journey
We have toolkits, manuals, websites, and monthly calls to learn from and with each other.
Your job is to join the calls, share with us your successes and more importantly the barriers you face.
Commit to the premise that harm is untenable.

21. To Get Help
/call state project leader
Talk to your team leader

22. Action Items Review content of website Toolkits Slidesets Manuals
Project Management Checklists
Pre-Implementation Checklist
CEO/ Senior Leader Checklist
Infection Preventionist Checklist

23. References Measuring Safety
Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications". JAMA. 2008; 299(18):
Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: An elusive target. JAMA. 2006; 296(6):
Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD, Miller MR. Measurement of quality and assurance of safety in the critically ill. Clin Chest Med. 2008; in press.

24. References Measuring Safety
Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for "preventable complications". JAMA. 2008; 299(18):
Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: An elusive target. JAMA. 2006; 296(6):
Pronovost PJ, Sexton JB, Pham JC, Goeschel CA, Winters BD, Miller MR. Measurement of quality and assurance of safety in the critically ill. Clin Chest Med. 2008; in press.

25. 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, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ Oct 6;337.
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):