1. Healthcare Safety: How will your next patient be injured?
Thomas Davis, CRNA
Chief CRNA
The Johns Hopkins Hospital

2. Why Safety and Why Now?

3. Your patients deserve it Insurance payers demand it
Why Safety and Why Now?
Your patients deserve it Insurance payers demand it

4. Protect your Reputation and Reimbursement
CMS monitors and reports outcome
Patients have access to National Database
APSF provides advisories regarding equipment, techniques and drugs.
Most important: Focus on safety because you owe it to your patients
Eliminate “never”events
Reduce high frequency risks.
CLABSI
VAP

5. Government will not pay when:
A foreign object is retained within a patient´s body after surgery.
The development of an air embolism within a patient´s body.
A patient blood transfusion with incompatible blood.
A patient´s development of stage III or stage IV pressure ulcers.
Patient injuries resulting from accidental falls and other trauma

6. Government will not pay when:
A patient has of poor glycemic control
A patient develops a catheter-associated urinary tract infection.
A patient develops a vascular catheter-associated infection.
A patient develops a surgical site infection following:
A coronary artery bypass graft - mediastinitis;
Bariatric surgery,
Orthopedic procedures, including, but not limited to, such procedures performed on the spine, neck, shoulder and elbow.
A patient develops deep vein thrombosis

7. Direct Benefits Increased Patient Satisfaction Staff engagement
Collaborative teambuilding across lines
Lean Sigma work flow gains
Financial rewards

8. How Do Hospitals Compare?

9. CUSP for Patient Safety
Continuous Unit Based Safety Program

10. Why the CUSP FORMAT? Improve safety culture and learn from mistakes
Can be implemented throughout organization
Values the wisdom of front line staff
Linked with improvement in clinical outcomes
Empowers staff to be actively involved
Reduces barriers between staff and senior leadership.
Armstrong Institute for Patient Safety

11. Building Your Safety Program
Build a CUSP
Must include ALL stakeholders
All CUSP members have an equal say
Engage Hospital leadership
Seek type 2 solutions
Make a long term commitment
Armstrong Institute for Patient Safety

12. The Process: Assemble a CUSP Team Assess your Safety Culture
Learn/Teach the Science of Safety
Identify Defects
Form Executive Partnerships
Learn from Defects
Develop Tools for Improvement
Armstrong Institute for Patient Safety

13. CUSP Team Members: Transdisciplinary and collaborative Team Leader
Surgeon Champion
Anesthesia Champion
Nursing Champion
Executive Champion
Frontline staff (PACU, ICU, OR, Surgical floors
Armstrong Institute for Patient Safety

14. Safety Culture Formal Survey (AHRQ)
HSOPS – Hospital survey of patient safety
NPSF has excellent PDF download
content/uploads/2011/10/PLS_1102_SS.pdf
Local Survey
How will our next patient be injured?
What can we do to prevent it?

15. Culture versus Outcome
The Health foundation, November 2011
As Safety Culture increased;
Readmission rates decreased
Length of ICU stay decreased
Complications decreased
Medication errors decreased
Adverse events decreased
Patient satisfaction increased

16. Science of Safety
Every system is perfectly designed to achieve the results it gets
Understand the principles of safe design
Standardize, checklists, learn from mistakes
Recognize that principles apply to technical and team work
Teams make wise decisions when there is diverse and independent input
Armstrong Institute for Patient Safety

17. Identify Defects How will the next patient be injured?
What can be done to prevent this harm?
Surgical site infection?
Production pressure?
Communication?
Prioritize your effort
Severity of harm
Frequency of harm

18. Form Executive Partnerships
Executive member is essential
Stimulates discussion
Helps prioritize efforts
Can lobby C-Level for policy change
Access to resources
Helps resolve inter-department issues
Must be committed and available for safety rounds

19. Learn From Defects What Happened? Why did it happen?
What did you do to reduce the risk?
How do you know the risk was reduced?

20. Form Executive Partnerships
Executive member is essential
Stimulates discussion
Helps prioritize efforts
Can lobby C-Level for policy change
Access to resources
Helps resolve inter-department issues
Must be committed and available for safety rounds

21. Develop Tools to Improve
CUSP for Safe Surgery website
Technical tools
Briefing/Debriefing tools
Checklists
Adaptive Tools
Perioperative daily huddle
Shadowing other professionals.

22. CUSP is an ongoing process, and is never truly finished.
Armstrong Institute for Patient Safety

23. So…How will your next patient What will you do to prevent it?
be harmed?
What will you do to prevent it?