1. CLABSI Supplemental Call Series How CUSP Enables Nurse Empowerment November 15, 2011 Presenters: Pat Posa, RN, BSN, MSA Joanne Timmel, MSN, RN, NE-BC

2. Slide 2 CLABSI Supplemental Call Series Pat Posa, RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Heath System

3. Slide 3 CUSP Components 1.Form a unit CUSP team with executive sponsorship 2.Measure unit culture 3.Educate staff on science of safety 4.Identify defects using the staff safety assessment; prioritize defects 5.Learn from one defect per quarter 6.Implement team and communication tools

4. Slide 4 How is CUSP Different? It Empowers Nurses Driven by frontline staff – Nurses Identifies problem areas: W hat staff think are impeding patient care vs. what managers/directors think are priority areas Designed for bedside caregivers – Easy for busy staff to use – Unit drives its own quality Can complement other quality improvement methods – must use multiple tools

5. Slide 5 St. Joseph Mercy Hospital’s Journey Keystone ICU: Statewide ICU collaborative (2003) Multidisciplinary Keystone (CUSP) team met monthly Annual culture assessment with staff developing action plans to improve culture Executive rounds Learn from defects Team/communication tools: – Multidisciplinary rounds with daily goals – Crucial conversation training – Structured huddles

6. Slide 6 Best Practices: Learning from Defects Tool

7. Slide 7 Best Practices : Engaging & Sustaining Nurse Involvement in CUSP Huddles Enable teams to have frequent but short briefings so they can stay informed, review work, make plans, and move ahead rapidly Allow fuller participation of frontline staff and bedside caregivers, who often find it impossible to get away for hour-long improvement team meetings Keep momentum going because teams are able to meet more frequently Permits daily focus on unit outcomes and lets recovery begin immediately from defects (i.e., falls, sepsis) 7

8. Slide 8 Components Metric 1: Quality/Safety Metric 2: Patient Satisfaction Metric 3: Operations Daily Critical Communications Information Ideas in Motion How to do it? Beginning or mid shift 5-10 minutes Lead by member of unit leadership team 8

9. Slide 9 SICU Huddle Board 9

10. Slide 10 Surgical Unit Huddle Board

11. Slide 11 Lessons for Your Hospital: Strategies that Promote Nurses & Leverage CUSP Frontline staff are an integral part of the CUSP team Teams should meet monthly Nurses who work in the unit every day are the best people to identify where there are opportunities to improve and how to improve Nurses need to be allowed to take responsibility for identifying problems and be given a forum and strategy to solve them – CUSP team – Learn from defects tool – Structured huddles

12. Slide 12 A Healthcare Imperative “In medicine, as in any profession, we must grapple with systems, resources, circumstances, people, and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, we must improve.” Atul Gawande, Better: A Surgeon’s Notes on Performance

13. CLABSI Supplemental Call Series Joanne Timmel, MSN, RN, NE-BC Nurse Manager The John Hopkins Hospital

14. Slide 14 Implementing CUSP: Assumptions & Prerequisites Certain beliefs predispose for success – Direct care staff are best able to identify impediments to safe, efficient care – Staff value patient-centered care Manager has participative leadership style Setting is important -- a room on the unit boosts attendance Broad Team: Pharmacist, social worker, PT & OT, chaplain, environmental services, mid-level providers, residents, attending, administrator

15. Slide 15 Implementing CUSP: Engaging the Team Define CUSP for your setting Kick off with science of safety presentation Ask the question: “How will the next patient be harmed on our unit?”

16. Slide 16 CUSP: How it Empowers Nurses in the Hospital Nurses are empowered when — They see change happen Their concerns are affirmed They develop a voice and can tell their story They are supported by a unit culture that values speaking up regarding patient safety Nurses are empowered when they actually have power

17. Slide 17 CUSP: Example of Empowerment A surgical unit before CUSP — Chaos Unclear plan of care Very poor communication with the surgeons Patients frustrated and angry at nurses Nurses felt powerless, so they left — high turnover

18. Slide 18 CUSP: Example of Empowerment Our first CUSP project: Proposed cohorting Implemented nurse-physician joint rounds Developed a written daily goal sheet generated from rounds Established other mechanisms for non-urgent communication besides rounds Continued to articulate collaborative culture by hosting First Monday breakfasts

19. Slide 19 CUSP: Example of Empowerment Nurses now have a place to address day-to-day intransigent system problems Medications not available when due Pain control issues in admitted outpatients Inpatient nurse/PACU nurse communication Contributing factors to recent medication errors New residents’ lack of familiarity with POE system Strategies for coverage with decreased resident hours Pain control issues/narcotics issues with patients with chronic pancreatitis, Interventional Radiology patients

20. Slide 20 Best Practices: Engaging & Sustaining Nurse Involvement in CUSP Absolutely requires three strong champions: Nurse, physician, administration Monthly meetings require email reminders, individual invites, reminders throughout day, support to allow staff to step away from patients Energy maintained when you focus on what matters to the bedside nurse Really resolve some problems

21. Slide 21 Lessons for Your Hospital: Strategies that Promote Nurses with the Leverage of CUSP If nurses are not engaged in the CUSP process, ask why Are you trying to lower CLABSI rates by ultimately requiring nurses to do more when they know they aren’t able to do half of what they expect of themselves? Find low-hanging fruit (e.g., need red labels on high-concentration PCA)

22. Slide 22 Questions?