1. Cardiac Surgery CER Project: The Comprehensive Unit Based Safety Program (CUSP)
An Intervention to Learn from Mistakes and Improve Safety Culture
Chris Goeschel
BNVBBVB

2. Immersion call Schedule
Title
Date /Time 13:00 EST
Presented by
Program Overview
Feb 18, 2011
Peter Pronovost MD PhD
Science Of Safety
February 25, 2011
Jill Marsteller, PhD, MPP
Comprehensive Unit-Based Safety Program CUSP
March 4, 2011
Christine Goeschel MPA MPS ScD RN
Central Line Blood Stream Infection Elimination
March 11, 2011
David Thompson DNSC, MS
Surgical Site Infection Elimination
March 18, 2011
Elizabeth Martinez, MD, MHS
Ventilator-Associated Pneumonia Reduction
March 25, 2011
Sean Berenholtz, MD
Hand-Offs: Transitions in Care
April 1, 2011
Ayse Gurses, PhD
Data we Can Count on
April 8, 2011
Lisa Lubomski, PhD.
Team Building
April 15, 2011
Physician Engagement
April 22, 2011
Peter Pronovost, MD, PhD

3. Learning Objectives To explain the philosophy and approach of CUSP
To describe the steps in CUSP
To introduce teamwork tools that help improve safety

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

5. The Vision of CUSP
The Comprehensive Unit-based Safety Program is a designed to:
educate and improve awareness about patient safety and quality of care
empower staff to take charge and improve safety in their work place
partner units with a hospital executive to improve organizational culture and provide resources for unit improvement efforts
provide tools to investigate and learn from defects
Must educate staff so they have the knowledge to improve their workplace.
Must be staff driven or they won’t be empowered to take charge and improve care.

6. The QSRG Model to Improve Care
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
Translating Evidence Into Practice
(TRiP)
Summarize the evidence in a checklist
Identify local barriers to implementation
Measure performance
Ensure all patients get the evidence
Engage
Educate
Execute
Evaluate
Central line Associated Bloodstream Infections (CLABSI)
Wash your hands prior to procedure
Clean insertion site with chlorhexidine
Use full barrier precautions
Avoid the femoral site
Ask every day if lines can be removed

7. The QSRG Model to Improve Care
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
Translating Evidence Into Practice
(TRiP)
Summarize the evidence in a checklist
Identify local barriers to implementation
Measure performance
Ensure all patients get the evidence
Engage
Educate
Execute
Evaluate
Reducing Surgical Site Infections

8. The QSRG Model to Improve Care
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
Translating Evidence Into Practice
(TRiP)
Summarize the evidence in a checklist
Identify local barriers to implementation
Measure performance
Ensure all patients get the evidence
Engage
Educate
Execute
Evaluate
Reducing Ventilator Associated Pneumonia

9. Pre CUSP Work Create a CUSP/CLABSI team
Nurse, physician administrator, others
Assign a team leader
Measure culture in the unit* (Hospital Survey of Patient Safety “HSOPS”)
Work with hospital quality leader or hospital management to have a senior executive assigned to CUSP team
Discuss culture measurement with hospital association leader (how, what instrument, when)

10. Steps of CUSP Educate staff on Science of Safety 2. Identify defects
(video download available at )
2. Identify defects
3. Assign executive to adopt unit
4. 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

11. 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.

12. 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
List and prioritize all defects

13. Step 2: Identify Defects
Complete the Staff Safety Assessment

14. Staff Safety Assessment Results
*2 answered unit is safe

15. Prioritize Defects List all defects
Discuss with staff what are the three greatest risks
Use Learning from Defect Tool to guide your efforts

16. Step 3: Executive Partnership
Executives should become a member of CUSP teams (Surgery; ICU; Floor)
Executive meets at least monthly with team
review defects identified on staff safety survey
work with team and develop plan to reduce risks
ensure team has resources to implement plan
Executive holds team accountable during monthly review of:
action plans; infection data; team checkup data
HSOPS (culture) data and Staff Safety Assessment data
(each survey is conducted annually and results used throughout the year)

17. Step 4: Learning from Mistakes
Select a specific defect
What happened?
Why did it happen (system lenses) ?
What could you do to reduce risk ?
How do you know risk was reduced ?
Creates early wins for the project
Pronovost 2005 JCJQI

18. Step 4: Learning from Mistakes
Select a Specific Defect
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

19. What Happened? Reconstruct the timeline and explain what happened
Put yourself in the place of those involved, in the middle of the event as it was unfolding
Try to understand what they were thinking and the reasoning behind their actions/decisions
Try to view the world as they did when the event occurred
Source: Reason, 1990;

20. Why did it Happen?
Develop lenses to see the system (latent) factors that lead to the event
Often result from production pressures
Damaging consequences may not be evident until a “triggering event” occurs
Source: Reason, 1990;

21. What will you do to Reduce Risk?
Develop list of interventions
For each Intervention rate
How well the intervention solves or reduces the problem
The team belief that the intervention will be used as intended
Select top interventions (2 to 5) and develop intervention plan
Assign person, task follow up date

22. What will you do to Reduce Risk ?
Safe design principles
Standardize what we do
Eliminate defects
Create independent check
Make it visible
Safe design applies to technical and team work

23. Rank Order of Error Reduction Strategies
Most Effective
Forcing functions and constraints
Automation and computerization
Standardization and protocols
Checklists and double check systems
Rules and policies
Education / Information
Least effective
Be more careful, be vigilant

24. 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

25. Summarize and Share Findings
Summarize findings
1 page summary of 4 questions
Share within your organizations
Share de-identified with others in collaborative (pending institutional approval)

26. Identified concern from Staff Safety Assessment (CUSP Step 2)
Recommended Improvements
(CUSP Step 4 & 5)
Interventions Implemented
Risk of central line associated bloodstream infections
Make sure best practices are used for all central lines insertions.
A line cart and checklist is used for all central lines insertions.
Risk of central line associated bloodstream infections due to poor compliance with IV tubing changes
Make sure every central line IV tubing is changed according to best practice.
New IV tubing labeling system used.
Risk of medication errors
Point of care pharmacist available on units
Pharmacist assigned
Poor management of pain
Create guideline or protocol for pain assessment and management
Pain card at every bedside
Poor communication among ICU providers
Create Short Term (Daily) Goals Sheet
Short term goals sheet used during rounds
Poor communication during ICU discharge leading to medication errors in transfer orders
Implement medication reconciliation process at ICU discharge
Medication reconciliation done at discharge

27. Improve Pain Management
Educate Staff
Put visual analog pain scale (VAS) card at bedside
Have residents report pain scores
Define defect as pain score > 3
Skip if local example is long
Erdek Pronovost
Erdek & Pronovost

28. Improve Pain Assessment
Skip if local example is long

29. Improve Pain Management
Skip if local example is long

30. Step 5: Teamwork Tools Daily Goals Morning Briefing
J Crit Care 2003;18(2):71-75
Morning Briefing
Jt Comm J Qual Patient Saf. 2005;31(8):476-9
Learning from Defects
Jt Comm J Qual Patient Saf. 2006;32(2):102-8
Am J Med Qual 2009;24(3):192-5.
Team Check Up Tool
Jt Comm J Qual Patient Saf. 2008;34:
Shadowing
Jt Comm J Qual Patient Saf. 2008;34:614-8

31. Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence:
caregivers feel comfortable speaking up if they perceive a problem with patient care
% of respondents within an ICU reporting good teamwork climate
No BSI 21%
No BSI 44%
No BSI 31%
No BSI = 5 months or more w/ zero
Health Services Research, 2006;41(4 Part II):1599.

32. CUSP Lessons Learned Culture is local Not linear process
Implement in a few units, adapt and spread
Include frontline staff on improvement team
Not linear process
Iterative cycles
Takes time to improve culture
Couple with clinical focus
No success improving culture alone
CUSP alone viewed as ‘soft’
Lubricant for clinical change

33. Your Role Create Unit Level CUSP teams
Train all staff in the science of safety
Identify hazards
Partner with senior executives
Learn from one defect per month
Try teamwork tools 33

34. 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):