1. The Comprehensive Unit Based Safety Program (CUSP)
An Intervention to Learn from Mistakes and Improve Safety Culture
Paula Kent, MSN, MBA
September 11, 2012
Armstrong Institute for Patient Safety and Quality
Conference Number(s):
Participant Code:

2. On Boarding Call Schedule
Program Introduction
Building Your CUSP Team
Science of Safety –September 4,
CUSP - September 11,
VAP Evidence- September 2:00pm
Daily Goal Review -September 25, 2:00pm

3. 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 CUSP for VAP:EVAP project goals:
To achieve significant reductions in VAP rates and complications related to mechanical ventilation
To achieve significant improvements in safety culture

4. AN INTRODUCTION TO CUSP
Part I
AN INTRODUCTION TO CUSP

5. 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

6. Armstrong Institute for Patient Safety and Quality
CUSP vs. VAP?
CUSP is an Intervention to Learn from Mistakes and Improve Safety Culture
CUSP is the safety foundation that supports the efforts to reduce VAP rates by translating evidence into practice (TRiP)
Armstrong Institute for Patient Safety and Quality

7. The Armstrong Institute Model to Improve Care
Comprehensive Unit based Safety Program (CUSP)
Educate staff on science of safety
Identify defects
Recruit executive to adopt unit
Learn from one defect per quarter
Implement teamwork tools
Translating Evidence Into Practice
(TRiP)
Summarize the evidence
Identify local barriers to implementation
Measure performance
Ensure all patients get the evidence
Engage
Educate
Execute
Evaluate
Eliminating Ventilator Associated Pneumonia
Emerging Evidence
Local Opportunities to Improve
Collaborative learning
Technical Work
Adaptive Work

8. Pre-CUSP Work Create a CUSP team
Nurse, physician, administrator, respiratory therapist, 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 CUSP team

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

10. A ‘WALK THROUGH’ OF THE CUSP PROCESS
Part II
A ‘WALK THROUGH’ OF THE CUSP PROCESS

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

12. 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

13. Step 2: Identify Defects
Two-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

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

15. Step 3: Recruit Executive as Active CUSP 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
Wick et al. 2012

16. Step 4: Learning from Defects (LFD)
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 (“go after the low hanging fruit”)
Berenholtz, et al
Pronovost, et al

17. Learning from Defects and VAP
There are systems defects that contribute to the incidence of VAP.
Many of these are related to the implementation of VAP prevention processes.
Learning from defects analysis can help identify where the systems that should support these processes fall short.

18. VAP Prevention Processes: Opportunities for Improvement
Head of Bed Elevation (HOB)
Use of a semi-recumbent position ( ≥ 30 degrees).
Spontaneous Awakening and Breathing Trials (SAT & SBT)
Daily assessment of sedation and readiness to wean
Oral Care
At least 6 times per day
Oral Care with Chlorhexidine (CHG)
Should be included in the oral care regimen 2 times per day
Subglottic Suctioning Endotracheal Tubes (ETTs)
Use subglottic suctioning ETTs in patients expected to be mechanically ventilated for >72 hours
Wick et al

19. Opportunities for Improvement: Policy-Based Structural Measures
Use a closed ETT suctioning system
Change close suctioning catheters only as needed
Change ventilator circuits only if damaged or soiled
Change HME every 5-7 days and as clinically indicated
ETT endotrachael tube; HME heat moist exchanger

20. Use early mobility protocol
Opportunities for Improvement: Policy-Based Structural Measures, cont’d
Provide easy access to NIVV equipment and institute protocols to promote use
Periodically remove condensate from circuits, keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient
Use early mobility protocol
NIVV non-invasive ventilation
Nundy et al. 2008
Henrickson et al. 2009
Berenholtz et al. 2009
Haynes et al. 2009

21. Opportunities for Improvement: Policy-Based Structural Measures, cont’d.
Perform hand hygiene
Avoid supine position
Use standard precautions while suctioning respiratory tract secretions
Use orotracheal intubation instead of nasotracheal
Avoid use of prophylactic systemic antimicrobials
Avoid non-essential tracheal suctioning
Avoid gastric over-distention

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

23. 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

24. 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

25. 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’

26. Action Items
Ensure CUSP 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 CUSP team membership form (available from your hospital association)
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 26

27. Complete and submit the commitment/enrollment forms
Finalize enrollment
Complete and submit the commitment/enrollment forms
Questions or comments:
Karol G. Wicker, MHS
Senior Director, Quality Policy & Advocacy
Maryland Hospital Association
Mary Catanzaro RN BSMT CIC
Project Manager HAIs
Hospital and Healthsystem Association of Pennsylvania

28. References
Slide 5: Accessed September 17th Slide 9: 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 14: 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 15: 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 18: 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]

29. Armstrong Institute for Patient Safety and Quality
References
Slides : 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 23: 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 24: 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