1. Staff Safety Assessment1

2. Learning Objectives To understand Step 2 of CUSP:Identify Defects
To understand how to Implement the Staff Safety Assessment
To understand ways to use results of the Staff Safety Assessment 2

3. Goals To identify defects
To leverage the wisdom of the front line worker
To prepare a list of improvement opportunities that has face validity and provides a focus for CUSP activities. 3

4. On the CUSP: Stop BSI CUSP CLABSI 4 Educate staff on science of safety
Identify defects
Assign executive to adopt unit
Learn from one defect per quarter
Implement teamwork tools
Remove Unnecessary Lines
Wash Hands Prior to Procedure
Use Maximal Barrier Precautions
Clean Skin with Chlorhexidine
Avoid Femoral Lines 4

5. The smaller group that spreads the intervention
The CUSP Team
The smaller group that spreads the intervention
to the rest of the unit 5

6. Education and engagement activities on the unit
BSI: Providing Evidence, Modeling the line placement steps; stopping insertions that violate protocol; having one-on-one talks where necessary;
Facilitating CUSP Activities 6

7. 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
We are here
Comprehensive Unit-based Safety Programs can improve culture
You are here!!! 7

8. Identify Defects
Review error reports, liability claims, sentinel events or M and M conference
Ask staff how the next patient will be harmed 8

9. Identifying Defects
What SHOULD you know?
What DO you know? 9

10. Making project and progress visible to everyone
Transparency
Making project and progress visible to everyone 10

11. How are We Going to Harm the Next Patient?
One way to make harm visible-- get staff thinking about safety and how to improve it 11

12. Step 2: Staff Identify Defects
Frontline caregivers are the eyes and ears of patient safety
Identify clinical or operational problems that negatively impact patient safety (have or could)
Use the Staff Safety Assessment form (Part of CUSP manual)
How will the next patient will be harmed in our unit
What can be done to minimize patient harm or prevent this safety hazard
ICU managers and team review suggestions, set the agenda for discussion with executive partner 12

13. 13

14. Step 2: Staff Identify Defects
What Team Leaders need to do:
Hand out a Staff Safety Assessment form to all staff, clinical and non-clinical, in the unit
Establish a collection box or envelope
Identify and group common defects (such as communication, medications, patient falls, supplies, etc.)
Summarize as frequencies (i.e., what percent of responses were for communication) 14

15. Prioritize Defects List all defects
Discuss with staff what are the three greatest risks 15

16. Step 2: Staff Identify Defects
Report the identified defects to staff, executive partner
ICU managers and CUSP team prioritize defects identified by the potential level of risk to the patient
Select one to work on with support of Executive
Step 2 should be ongoing 16

17. 17

18. 18

19. CUSP Team activities- keeping on track
Team meetings (recommend monthly)
Review of data (monthly)
Meet w/ Exec Partner (monthly or more)
Executive review of data (monthly)
Presentations to hospital colleagues
(leadership, frontline staff, board) 19

20. 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 20

21. 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
We are here
Comprehensive Unit-based Safety Programs can improve culture
You are here!!! 21

22. What Should you do NOW? CUSP Implementation
CLABSI: Collect & Submit Baseline & Monthly BSI data
CUSP Preparation: Assemble team/Schedule meetings
CUSP Implementation
Science of Safety Training for all staff
Identify Defects: How will patients be harmed? 22

23. References
Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: A model for large scale knowledge translation. BMJ. 2008; 337:a1714.
Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. NEJM. 2006; 355(26):
Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in michigan. J Crit Care. 2008; 23(2):
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 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. 23