1. Small Rural/CAH Learning Community Meeting May 23, 2012 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement

2. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Learning Objectives 1.Describe the Comprehensive Unit-based Safety Program. 2.Identify 3 essential elements of CUSP. 3.Discuss how using CUSP tools can increase sustain patient safety on a unit.

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. The Challenge How do we provide and sustain the highest quality and safest care for every patient, every time in the current environment of diminishing resources?

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Ensure Patients Reliably Receive Evidence Pronovost: Health Services Research, 2006

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. What is CUSP? Comprehensive Unit-based Safety Program An intervention to learn from mistakes and improve safety culture for sustained improved patient outcomes

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Safety/Quality Improvement Is A Two Part Process

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. On the CUSP: Process Intervention Comprehensive Unit-based Safety Program (CUSP) -Improve or reinforce good cross- disciplinary communication and teamwork -Enhance coordination of care -Address overall patient safety -Work towards healthy unit culture Reduction Protocol -Best-evidence supplies, organization of supplies -Ensuring all patients receive the best practices -Checklist, protocol to ensure consistent application of evidence On the CUSP

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. The CUSP Steps 1.Educate staff on Science of SafetyEducate staff on Science of Safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from defects 5.Implement teamwork tools Pronovost J, Patient Safety, 2005

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Step 1: Science of Safety Understand system determines performance Use strategies to improve system performance – Standardize – Create independent checks for key process – Learn from mistakes Apply strategies to both technical work and team work Recognize teams make wise decisions with diverse and independent input http://www.onthecuspstophai.org/StopManu-7618.html.

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Step 2: Identify Defects Review quality data, error reports, liability claims, sentinel events or Morbidity/Mortality conference Perform Staff Safety Assessment - Ask staff how will the next patient be harmed

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Prioritize Defects List all defects, area for improvement Discuss with staff what are the three greatest risks

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Step 3: Executive Partnership Executive should become a member of unit team Executive should meet monthly with unit team Executive should review defects, ensure unit team has resources to reduce risks, and hold team accountable for improving risks and patient outcomes

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Step 4: Learning from Each Incident What happened? Why did it happen (system lenses) ? What could you do to reduce risk ? How do you know risk was reduced ? – Create policy / process / procedure – Ensure staff know policy/process – Evaluate if policy/process is used correctly Pronovost 2005 JCJQI

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Step 4: Identify Most Important Contributing Factors Rate each contributing factor – Importance of the problem and contributing factors in causing the accident/incidence – Importance of the problem and contributing factors in future accidents

15. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Step 4: Identify Most Effective Interventions Use QI tools to identify effective intervention/process Rate Each Intervention – How well the intervention solves the problem or mitigates the contributing factors for the accident – Rate the team belief that the intervention will be implemented and executed as intended

16. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Step 4: Evaluate Whether Risks Were Reduced Did you create a new process/policy or procedure Do staff know about the new process/policy Are staff using it as intended Do staff believe risks have been reduced

17. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Step 5: Teamwork Tools – Improving Communication and Process TeamSTEPPS Tools Daily goals AM briefing Shadowing Call list Creating an environment where all feel safe to speak up for safety Culture check up Pronovost JCC, JCJQI

18. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Other Improvement Tools PDSA Lean/Six Sigma Reliable System Process Design Transforming Care at the Bedside – Snorkeling, Deep Dive Progress reports to staff and leadership Other tools

19. Learn. Act. Improve. Spread. Keep the Drum Beat Going. CUSP Model On The CUSP Technical – Practices to Prevent Harm Evidence Based Practice 1. Evaluation 2. Systems Analysis 3. Process Development Education on the Evidence 1. Presentation of evidence 2. Fact Sheet 3. Cost Estimator 4. Summary of Professional Organization Recommendations 5. Annotated bibliography Implementation/ Sustaining 1.Checklist 2.Policy / Procedures 3. Protocol s 4. Monitoring 6. Feedback Adaptive (CUSP) Science of Safety 1. Science of Safety presentation 2. Attendance sheet Staff Identify Defects 1.Staff Safety Assessment form 2.Identifying Hazards presentation Senior Executive Partnership 1. Education 2. Briefings Learning from Defects 1. LFD toolkit 2.RCA of each incidence Implement Tools for Teamwork and Communication 1. Daily Goals 2. Shadowing 3. AM Briefing 4. Call List 5. Team Check Up tool 6. TeamSTEPPS Tools Assemble a CUSP team, Partner with a Senior Executive; Baseline Data Quality Improvement Tools 1. PDCA 2. Lean/Six Sigma 3. Reliable System Process 4. TCAB 5. Other

20. Learn. Act. Improve. Spread. Keep the Drum Beat Going. CUSP is a Continuous Effort Add Science of Safety education to orientation Learn from one defect per quarter, share or post lessons Implement teamwork tools that best meet the unit’s needs More details are in the CUSP manual

21. Learn. Act. Improve. Spread. Keep the Drum Beat Going. References Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003; 18(2):71-75. Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68. Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):476-479.

22. Learn. Act. Improve. Spread. Keep the Drum Beat Going. CUSP: Stop HAI Web Site Tools, Education, Resources http://www.onthecuspstophai.org. http://www.onthecuspstophai.org

23. Learn. Act. Improve. Spread. Keep the Drum Beat Going. CONTACT INFORMATION Denise Flook dflook@gha.orgdflook@gha.org. 770-249-4518