1. The Comprehensive Unit Based Safety Program (CUSP)
An Intervention to Learn from Mistakes and Improve Safety Culture

2. 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 SUSP project goals:
To achieve significant reductions in surgical site infection rates and surgical complications
To achieve significant improvements in safety culture

3. An Introduction to CUSP
Part I
An Introduction to CUSP

4. 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

5. Armstrong Institute for Patient Safety and Quality
CUSP or SUSP?
CUSP is an Intervention to Learn from Mistakes and Improve Safety Culture
SUSP is a national collaborative project to improve surgical care through TRiP and CUSP
Armstrong Institute for Patient Safety and Quality

6. SUSP: Improving Surgical Care Through TRIP and CUSP
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 **
Emerging Evidence
Local Opportunities to Improve
Collaborative learning
** and other surgical complications
Adaptive Work
Technical Work

7. Pre-SUSP Work Create a SUSP team
Nurse, physician, administrator, 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 SUSP team
Start in one area or service line (i.e., colon surgery), and then spread to others

8. 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 SUSP team member
4. Learn from one defect per quarter
Implement teamwork tools
Timmel, et al

9. A ‘walk through’ of the CUSP process
Part II
A ‘walk through’ of the CUSP process

10. 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 for mistakes
Apply strategies to both technical work and team work
Recognize teams make wise decisions with diverse and independent input

11. 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

12. Step 2: Identify Defects
2 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

13. Tap Into Staff Wisdom: How Will the Next Patient be Harmed?
Percent age of Responses (%)
148 answers from 51 staff members
Schwengel, et al

14. How will the next patient be harmed? (SSI Specific)
95 Responses from 36 Staff Members
Percentage of Responses (%)
Wick, et al

15. Step 3: Recruit Executive as Active SUSP 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

16. Step 4: Learning from Defects
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
Berenholtz, et al
Pronovost, et al

17. Identifying Safety Issues and Opportunities for Improvement
CUSP Step 2:
Safety Issue Identified
CUSP Steps 4 & 5:
Opportunities to improve
Infection Control
Skin preparation
Hypothermia
Contamination of bowel contents into the wound
Antibiotic timing
Selection and redosing
Length of case
Coordination of Care
Increase utilization of preoperative evaluation center,
Improve surgical posting accuracy (case name and duration)
Computer assistance for antibiotic selection and redosing
Communication and Teamwork
Improve communication throughout perioperative period
Empower team members to speak up
Improve compliance with briefings/debriefings
Implement teamwork tools
Equipment/ Supplies
Accurate temperature probes
Point of care glucose monitoring
Under body warmers
Sanitizing wipes near anesthesia machine
Policies/Protocols
Standardize care/protocols/policies
Monitor sterile technique policies
Education/Training
Ongoing education (with supportive data)
Development of a SSI prevention checklist
Wick, et al

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

19. Why Briefings and Debriefings Matter
Reductions in communication breakdowns and OR delays 1
Reductions in procedure and miscommunication-related disruptions and nursing time spent in core 2
Improved communication and teamwork, feasible given current workload 3
Reductions in rate of any complications, SSI and mortality 4
1 Nundy, et al
2 Henrickson, et al
3 Berenholtz, et al
4 Haynes, et al

20. 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

21. Wrong-Patient, Wrong-Site, Wrong-Procedure Events
The Joint Commission, Sentinel Event Data;

22. Armstrong Institute for Patient Safety and Quality
Michigan CUSP Results
“Needs Improvement”: Less than 60% of respondents reporting good safety or teamwork climate
Statewide in 2004, 82-84% needed improvement, in %
Pronovost, et al
Sexton, et al. 2011
Armstrong Institute for Patient Safety and Quality

23. 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’

24. Next Steps
Ensure SUSP team members who could not attend this call access archived materials at the Armstrong Institute (AI) website
_projects/action_II/SUSP/
Continue to form your team with an appreciation of the importance of WHO is on the team
Complete the SUSP team membership form (available at the AI website)
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 24

25. On-boarding Call Evaluation
We want to ensure that the on-boarding calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link:
If you are not able to reach the link from the slide, please cut & past the URL into your browser.
Armstrong Institute for Patient Safety and Quality

26. Armstrong Institute for Patient Safety and Quality
References
Slide 8: 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: Slide 13: 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 Dec;25(4): Slide 14: 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 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): 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: Slide 17 : 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 May 23. [Epub ahead of print]
Armstrong Institute for Patient Safety and Quality

27. Armstrong Institute for Patient Safety and Quality
References
Slide 19: 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): 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: 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: Slide 20: 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: Slide 22: Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23: 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