1 national content webinar cusp: a framework for success march 7, 2012

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National Content Webinar

CUSP: A Framework for Success

March 7, 2012

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Today’s Speakers

• Marge Cannon, Medical Officer, CMS• Minet Javellana, Health Insurance Specialist, CMS• Barb Edson, Vice President of Clinical Quality, HRET• Chris George, Director of National Projects, MHA Keystone Center• Chris Goeschel, Director of Strategic Development and Research

Initiatives at Armstrong Institute for Patient Safety and Quality, John Hopkins University

• Mary Jo Skiba, Project Manager QI/Research, Alpena Regional Medical Center

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Working Together – The Players

• Centers for Medicare & Medicaid Services Quality Improvement Organization (CMS QIO)

• Agency for Health Care Research and Quality (AHRQ)• On the CUSP: Stop HAI www.onthecuspstophai.org• CLABSI National Project Team – Michigan Health & Hospital Association - Michigan Keystone Center for Patient

Safety & Quality (MHA Keystone)– Armstrong Institute for Patient Safety and Quality Johns Hopkins University

(JHU)– Health Research & Educational Trust (HRET), research affiliate of the American

Hospital Association

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Learning Objectives

• Understand CUSP impact on safety• List CUSP components • Describe how a hospital implemented

CUSP

The Michigan CUSP Experience

Chris George, RN MSDirector of National Projects

Michigan Health & Hospital AssociationKeystone Center for Patient Safety & Quality

It is not just a simple checklist

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CUSP – The Michigan Experience

Use of CUSP tied with a technical intervention, such as central line-associated blood stream infection prevention “checklist.”

“Knowing the difference between adaptive and technical challenges is one of the key tasks of leadership.”

Ronald A. Heifetz

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ICU Safety Climate

Effect of CUSP on Safety Climate

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Pre vs. Post Intervention

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Pre-CUSP (2004) Post-CUSP (2006)

* “Needs Improvement” - Safety Climate Score <60%

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Culture / Climate and Outcomes

No BSI = 5 months or more w/ zero

The strongest predictor of clinical excellence: Caregivers feel comfortable speaking up if they perceive a problem with

patient care

Attribution: J. Bryan Sexton

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ICU Safety Climate

Effect of CUSP on Safety Climate

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Pre vs. Post Intervention

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Pre-CUSP (2004) Post-CUSP (2006)

* “Needs Improvement” - Safety Climate Score <60%

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RN Teamwork Climate Staff Physician Teamwork Climate

Teamwork Climate &Annual Nurse Turnover

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High Turnover 16.0%High Turnover 16.0% Low Turnover 7.9%Low Turnover 7.9% Mid Turnover 10.8% Mid Turnover 10.8%

“The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”

Man and SupermanGeorge Bernard Shaw

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The Comprehensive Unit-based Safety Program

The Comprehensive Unit-based Safety Program (CUSP): An Intervention to Learn from Mistakes and Improve

Safety Culture

Chris Goeschel, ScD MPA MPS RN FAAN Director, Strategic Development and Research Initiatives at

Armstrong Institute for Patient Safety and Quality Johns Hopkins University

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Ideas for Ensuring Patients Receivethe Interventions: the 4Es

• Engage: Stories, show baseline data

• Educate staff on evidence

• Execute– Standardize: Create line cart– Create independent checks: Create BSI checklist– Empower nurses to stop takeoff– Learn from mistakes

• Evaluate– Feedback performance– View infections as defects

Ensure Patients Reliably Receive Evidence

  Senior TeamStaffleaders leaders

Engage How does this make the world a better place?

Educate What do we need to do?

ExecuteWhat keeps me from doing it?

How can we do it with my resources and culture?

Evaluate How do we know we improved safety?Pronovost: Health Services Research, 2006

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Measure

Have We Created a Safe Culture?How Do We Know We Learn

From Mistakes?

CUSPComprehensive Unit-based Safety

Program

1.Educate staff on science of safety2.Identify defects3.Assign executive to adopt unit4.Learn from one defect per quarter5.Implement teamwork tools

How Often Do We Harm?Are Patient Outcomes

Improving?

(TRiP) Translating Evidence Into Practice

1. Summarize the evidence in a checklist2. Identify local barriers to

implementation3. Measure performance4. Ensure all patients get the evidence

Improve

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What is CUSP?What is CUSP?

• Comprehensive Unit-based Safety Program

• An intervention to learn from mistakes and improve safety culture

www.onthecuspstophai.org

BSI-Reduction Protocol

-Best-evidence supplies, organization of supplies

-Ensuring all patients receive the best practices

-Checklist to ensure consistent application of evidence

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

On the CUSP: Stop BSI Intervention

Pronovost, Berenholtz, Needham BMJ 2008

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Safety Score CardKeystone ICU Safety Dashboard

2004 2006How often did we harm (BSI)? (median) 2.8/1000 0How often do we do what we should? 66% 95%How often did we learn from mistakes?* 100s 100sHave we created a safe culture? What areas need improvement?

Safety climate* 84% 43% Teamwork climate* 82% 42%

* CUSP is intervention to improve these

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Pre CUSP Work

• Create a CUSP team– Nurses, physician, support staff, infection preventionist– Assign a team leader

• Measure culture in the unit• Work with hospital quality leader or hospital

management to have a senior executive assigned to CUSP team

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Steps of CUSPSteps of CUSP

1. Educate staff on science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

Pronovost J, Patient Safety, 2005

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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 teamwork

• Recognize teams make wise decisions with diverse and independent input

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Step 2: Identify Defects

•Administer the staff safety assessment and ask staff, “How will the next patient be harmed?”•Review error reports, liability claims, sentinel events,or M and M conference

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Prioritize Defects

• List all defects

• Discuss with staff what are the three greatest risks and what you should work on first

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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– Hold team accountable for improving risks and central line-

associated blood steam infection rate

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Step 4: Learning from Mistakes

• 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, or procedure– Ensure staff know policy– Evaluate if policy is used correctly

Pronovost 2005 JCJQI

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Step 4 cont’d: Identify Most Important Contributing Factors

• Rate each contributing factor

– Importance of the problem and contributing factors• In causing the accident • In future accidents

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Step 4 cont’d: Identify Most Effective Interventions

• 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

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Step 4 cont’d: Evaluate Whether Risks Were Reduced

• Did you create a policy or procedure• Do staff know about the policy• Are staff using it as intended• Do staff believe risks have been reduced

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Step 5: Teamwork Tools

• Call list• Daily goals• Morning briefing• Shadowing• Culture check up

Pronovost JCC, JCJQI

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Step 5 cont’d: Call List

• Ensure your unit has a process to identify which physician to page or call for each patient

• Make sure call list is easily accessible and updated

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Step 5 cont’d: Morning Briefing

• Have a morning meeting with charge nurse and unit attending(s) about the unit-level plan for the day

• Discuss work for the day– What happened during the evening– Who is being admitted and discharged today– What are potential risks during the day; how can we reduce these risks

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Step 5 cont’d: Shadowing

• Follow another type of clinician doing his or her job for between 2 and 4 hours

• Have the shadower discuss with staff what he or she will do differently now that he or she has walked in another person’s shoes

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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• Review details in the CUSP manual

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Action Items -- CUSP

• Look over the CUSP manual with team members• Brainstorm potential hazards with team • Assess team composition with respect to CUSP elements • Review pre-implementation checklist — where are you?

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Action Items

• Review content of Web site at www.onthecuspstophai.org• Toolkits• Slidesets• Manuals• Project Management Checklists

– Pre-Implementation Checklist– CEO/Senior Leader Checklist– Infection Preventionist Checklist

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ReferencesReferences

• 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, et al. 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, et al. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):476-479.

CUSP + CAUTI Process and Prevention

Mary Jo Skiba, RN BSNProject Manager QI/Research

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Objectives

• Apply CUSP interventions to CAUTI project• Remove barriers/identify steps to successful

CAUTI project initiation• Use CUSP to maintain success

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Science of Safety Education

• Education done prior to CAUTI• Safety survey to identify at-risk departments• Mandatory science of safety training

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Project Planning

• CAUTI Team• Policies • Awareness campaign• Data collection plan• Project start date• Education• Plan for follow-up

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Project Planning

• Establish and engage CAUTI team members– Involve frontline staff – Respect the wisdom– Have a physician champion– Include charge nurses/staff development– Engage an executive leader

• Identify defects– Review baseline data – CAUTI rate– Brainstorm safety concerns– Determine the scope of your initial project

• Policy - Urinary catheterization – Review, revise, consolidate– Use policy in toolkit– Don’t re-create the wheel

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Project Awareness

KEYSTONE HAI(Hospital Associated Infections)

“Bladder Bundle

Project”

Preventing Catheter-Associated Urinary

Tract Infections

• Hospital newsletter• Fliers• Screen savers

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Data Collection

• Data collectors• Data forms – Add qualifiers

specific to your hospital• Ensure understanding of

project requirements• 5 days week – Monday

through Friday (not weekends)

• Data entry with Web-based program

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Planning Education

Identify Defects -- Plan Ahead to Prevent Roadblocks • Nursing• Who will be trained• Who will train• How will we train• When will we train• How will we do makeups• How much ongoing

training or re-training needed

• Physicians• Who will train• How will we train• When will we train

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Educate on the Evidence

1. Didactic• CAUTI face-to-face inservice • All nursing/aides• Guideline for prevention of CAUTI • Physician CME• Department meetings

2. Demonstration of insertion competency

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Developing CAUTI Education

• Don’t re-create the wheel

• Use other hospitals’ PowerPoint slides

• Multiple CAUTI toolkits

• Update/revise to fit

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CAUTI EducationCAUTI Education

• Trained the trainers• Engaged frontline staff

Urinary Catheter Insertion Competency

• Traveling mannequin• 100 percent of aides and all nurse frequent

inserters (ED, OR, WHU, IP rehab, ICU)• Read policy• Take quiz• Perform procedure• Instant remediation and repeat demonstration

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Evaluate - Learn from Defects

• 167 Competencies • Average 15 min/staff member• 41 aides, 126 nurses

Improper cleaning 26Improper gloving 24Contaminated field 45Didn’t know needleless 30 cath port for specimens

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Execute New Plan

• Improvement plan for competency• Require field competency all aides within 2 months,

supervised by RNs• Newly hired aides trained by RNs • Yearly aide hands-on demo of competency

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Other Strategies

• Caths flagged with date of insertion• Secured to legs• Specimen collection for culture- Don’t use first urine drained from catheter - ED patients – Prior to collection, change catheter unless

known change within 7 days- Inpatients – If catheter in for 7 days must change prior to

specimen collection• Perineal hygiene prior to cath • “John Door” educational posters

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Outcome = Culture Change3.25

CAUTI’s/Month

1.17 CAUTI’s/Month

Identify Why Defects - CAUTIs

• Cath competency plan not followed• Focus was on EMR implementation• Daily cath patrol not consistent• Prevalence rates up

Execute New Plans

• Annual competency aide and ED/OR nurses • Imbedded competency orientation/annual skill

evaluations• Agenda item every leadership/staff meeting• Charge nurse daily cath patrol • Feedback monthly staff and physicians

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Execute New Plans

•Build cath necessity into EMR

•Consider decrease size standard cath - #16 to 14

•ED data capture of cath necessity

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CUSP - Not a Linear Process

“You might have to fight the battle more than once in order to win it.” (Margaret Thatcher)

Don’t worry alone. CUSP is a team sport.

“Shoot for the moon. Even if you miss, you'll land among the stars.” (Les Brown)

Questions?mjskiba@agh.org

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Polling Questions1) Have you ever heard of the Comprehensive Unit-based Safety Program (CUSP) before?

– I have never heard of CUSP

– I have heard of CUSP, but have not implemented it

– I have heard of CUSP, but have not successfully implemented it

– Have implemented CUSP successfully and actively using it in my unit

2) My senior executive regularly attends safety meetings on my unit, and can identify the top three safety issues that our safety team is currently working on:

– Very rarely attends and is out of touch with our unit safety issues

– Intermittently attends, and is somewhat aware of our unit safety issues

– Attends whenever possible, and is aware of our unit’s top three safety issues

3) By ensuring that your senior executive is a part of your safety team, meeting monthly with your unit team, and holding your unit team accountable for improving risks surrounding a hospital inquired condition, my unit will be successfully utilizing the executive partnership component of CUSP?

– No, not at all

– Not sure

– Yes, those are the main elements of the executive partnership component of CUSP

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