1. The Johns Hopkins Comprehensive Unit-based Patient Safety Program (CUSP) Peter Pronovost, MD, PhD, Johns Hopkins Univeristy

3. How can this happen? Improvements in safety represent the greatest opportunity to improve patient care

4. How can we improve “Every system is perfectly designed to achieve the results it gets”

5. Aviation Accidents per million departures

6. Primary accident causes (%)

7. Today, pilots can fail their certification based on poor interpersonal, or “non technical” aspects of their performance. Teamwork by Edict:

8. Lessons Learned: Focus on interpersonal improvements Frontline staff must assume responsibility for quality and safety Safety interventions must be goal directed Culture changes incrementally Document (measure) improvements

9. Johns Hopkins Comprehensive Unit-based Patient Safety Program (CUSP)

10. The Johns Hopkins Comprehensive Safety Program 1. Evaluate culture of safety 2. Educate staff on science of safety 3. Identify staff’s safety concerns 4. Executive adopt an ICU 5. Prioritize improvement efforts 6. Implement improvements 7. Share stories and disseminate results 8. Evaluate culture

11. Summary of Science of Safety The safety problem is large We will make mistakes We must focus on systems rather than people We need a culture to identify what is broken and fix it Leaders control the potential to change systems www.icusrs.org

12. NEJM

14. Evidence Regarding the Impact of ICU Organization on Performance Physicians Nurses Pharmacists Pronovost JAMA 1999, 20002 Pronovost JAMA 1999, 2002; Pronovost ECP 2001

15. Incident Reporting http:icusrs.org

16. What can we do to improve safety Accept that we make mistakes Focus on Systems – Prevent mistake from occurring – Make mistake visible – Mitigate harm should it occur Helmreich, Nolan

17. To prevent mistakes Create culture of safety Reduce complexity Create independent redundancy to ensure key processes occur – Evidence-based therapies – Bottle necks

18. Culture in Safe Organizations Commit to no harm Focus on systems not people Communication/teamwork – Assertive communication – Teamwork – Situational awareness – Disclosure Celebrate safety – Workers viewed as heroes

19. % of respondents within a clinic reporting good teamwork climate

20. % of respondents reporting above adequate teamwork

22. ISSUES IDENTIFIED ACROSS ICU’S Patient transport Medication errors Communication Central line infections

23. Percent Understanding Patient Care Goals

24. Impact on ICU Length of Stay 654 New Admissions: 7 Million Additional Revenue Daily Goals

25. ICU catheter-related blood stream infections NNIS Mean Education Line Cart Checklist 0 10 20 30 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar April May June July August Rate/1,000 Catheter days

27. Culture

28. % of respondents within a clinical area reporting good safety climate

29. What can you do: The safety program provides a practical, goal directed tool to improve safety culture and lead to measurable improvements in safety

30. NEXT STEPS Communication – Safety Tales – Sharing Lessons Learned Additional Training Nursing units and Departments Medical/nursing students

31. Is Safety your Hedgehog Concept What can you be great at What are you passionate about What is important Jim Collins

32. Who is willing to shave their Head Who is willing to commit to improving patient safety