cardiac surgery cer project: the comprehensive unit based safety program (cusp)
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Cardiac Surgery CER Project: The Comprehensive Unit Based Safety Program (CUSP). An I ntervention to L earn from M istakes and I mprove S afety C ulture Chris Goeschel [email protected]. Immersion call Schedule. Learning Objectives. To explain the philosophy and approach of CUSP - PowerPoint PPT PresentationTRANSCRIPT
Cardiac Surgery CER Project:Cardiac Surgery CER Project:The Comprehensive Unit Based Safety Program The Comprehensive Unit Based Safety Program
(CUSP) (CUSP) An Intervention to Learn from Mistakes and
Improve Safety Culture
Chris Goeschel [email protected]
© 2009
Immersion call ScheduleImmersion call Schedule
Title Date /Time 13:00 EST
Presented by
Program Overview Feb 18, 2011 Peter Pronovost MD PhD
Science Of Safety February 25, 2011 Jill Marsteller, PhD, MPP
Comprehensive Unit-Based Safety Program CUSP
March 4, 2011 Christine Goeschel MPA MPS ScD RN
Central Line Blood Stream Infection Elimination
March 11, 2011 David Thompson DNSC, MS
Surgical Site Infection Elimination March 18, 2011 Elizabeth Martinez, MD, MHS
Ventilator-Associated Pneumonia Reduction
March 25, 2011 Sean Berenholtz, MD
Hand-Offs: Transitions in Care April 1, 2011 Ayse Gurses, PhD
Data we Can Count on April 8, 2011 Lisa Lubomski, PhD.
Team Building April 15, 2011 Jill Marsteller, PhD, MPP
Physician Engagement April 22, 2011 Peter Pronovost, MD, PhD
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Learning ObjectivesLearning Objectives
• To explain the philosophy and approach of CUSP
• To describe the steps in CUSP
• To introduce teamwork tools that help improve safety
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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
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The Vision of CUSPThe Vision of CUSP
The Comprehensive Unit-based Safety Program is a designed to:
– educate and improve awareness about patient safety and quality of care
– empower staff to take charge and improve safety in their work place
– partner units with a hospital executive to improve organizational culture and provide resources for unit improvement efforts
– provide tools to investigate and learn from defects
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The QSRG Model to Improve CareThe QSRG Model to Improve Care
Comprehensive Unit based Safety
Program (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
Translating Evidence Into
Practice(TRiP)
1. Summarize the evidence in a checklist
2. Identify local barriers to implementation
3. Measure performance
4. Ensure all patients get the evidence
• Engage• Educate• Execute• Evaluate
www.safercare.net
Central line Associated
Bloodstream
Infections (CLABSI)
1. Wash your hands prior to procedure
2. Clean insertion site with chlorhexidine
3. Use full barrier precautions
4. Avoid the femoral site
5. Ask every day if lines can be removed
© 2009
The QSRG Model to Improve CareThe QSRG Model to Improve Care
Comprehensive Unit based Safety
Program (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
Translating Evidence Into
Practice(TRiP)
1. Summarize the evidence in a checklist
2. Identify local barriers to implementation
3. Measure performance
4. Ensure all patients get the evidence
• Engage• Educate• Execute• Evaluate
www.safercare.net
Reducing Surgical Site Infections
© 2009
The QSRG Model to Improve CareThe QSRG Model to Improve Care
Comprehensive Unit based Safety
Program (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
Translating Evidence Into
Practice(TRiP)
1. Summarize the evidence in a checklist
2. Identify local barriers to implementation
3. Measure performance
4. Ensure all patients get the evidence
• Engage• Educate• Execute• Evaluate
www.safercare.net
Reducing Ventilator Associated Pneumonia
© 2009
Pre CUSP WorkPre CUSP Work
• Create a CUSP/CLABSI team– Nurse, physician administrator, others– Assign a team leader
• Measure culture in the unit* (Hospital Survey of Patient Safety “HSOPS”)
• Work with hospital quality leader or hospital management to have a senior executive assigned to CUSP team
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Steps of CUSP
1. Educate staff on Science of Safety (video download available at www.safercare.net )
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 SafetyStep 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.safercare.net/OTCSBSI/Staff_Training/Entries/2009/9/6_1._The_Science_of_Improving_Patient_Safety.html
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Step 2: Identify DefectsStep 2: Identify Defects
• Review error reports, liability claims, sentinel eventsor M and M conference
• Ask staff how will the next patient be harmed
• List and prioritize all defects
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Step 2: Identify DefectsStep 2: Identify Defects
Complete the Staff Safety Assessment
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Staff Safety Assessment Staff Safety Assessment ResultsResults
N=24*
*2 answered unit is safe
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Prioritize DefectsPrioritize Defects
• List all defects
• Discuss with staff what are the three greatest risks
• Use Learning from Defect Tool to guide your efforts
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Step 3: Executive Step 3: Executive PartnershipPartnership
• Executives should become a member of CUSP teams (Surgery; ICU; Floor)
• Executive meets at least monthly with team review defects identified on staff safety survey
work with team and develop plan to reduce risks ensure team has resources to implement plan
• Executive holds team accountable during monthly review of:– action plans; infection data; team checkup data– HSOPS (culture) data and Staff Safety Assessment data (each survey is conducted annually and results used throughout the
year)
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Step 4: Learning from MistakesStep 4: Learning from Mistakes
• Select a specific defect
– What happened?
– Why did it happen (system lenses) ?
– What could you do to reduce risk ?
– How do you know risk was reduced ?
• Creates early wins for the project
Pronovost 2005 JCJQI
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Step 4: Learning from MistakesStep 4: Learning from Mistakes
Select a Specific Defect1. What happened?
2. Why did it happen (system lenses) ?
3. What could you do to reduce risk ?
4. How do you know risk was reduced ?1. Create policy / process / procedure2. Ensure staff know policy
5. Evaluate if policy is used correctly
Pronovost 2005 JCJQI
© 2009
What Happened?
• Reconstruct the timeline and explain what happened
• Put yourself in the place of those involved, in the middle of the event as it was unfolding
• Try to understand what they were thinking and the reasoning behind their actions/decisions
• Try to view the world as they did when the event occurred Source: Reason, 1990;
19
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Why did it Happen?
• Develop lenses to see the system (latent) factors that lead to the event
• Often result from production pressures
• Damaging consequences may not be evident until a “triggering event” occurs
Source: Reason, 1990;
20
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What will you do to Reduce Risk?
• Develop list of interventions
• For each Intervention rate– How well the intervention solves or reduces the problem– The team belief that the intervention will be used as
intended
• Select top interventions (2 to 5) and develop intervention plan– Assign person, task follow up date
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What will you do to Reduce Risk ?
• Safe design principles– Standardize what we do
− Eliminate defects
– Create independent check– Make it visible
• Safe design applies to technical and team work
© 2009
Rank Order of Error Reduction Strategies
Forcing functions and constraintsForcing functions and constraints
Automation and computerizationAutomation and computerization
Standardization and protocolsStandardization and protocols
Checklists and double check systems
Checklists and double check systems
Rules and policiesRules and policies
Education / InformationEducation / Information
Be more careful, be vigilantBe more careful, be vigilant
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Least effective
Most Effective
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Step 4 cont’d: Evaluate Whether Step 4 cont’d: Evaluate Whether Risks were ReducedRisks 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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Summarize and Share Findings
• Summarize findings– 1 page summary of 4 questions
• Share within your organizations
• Share de-identified with others in collaborative (pending institutional approval)
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Identified concern from Staff Safety Assessment
(CUSP Step 2)
Recommended Improvements
(CUSP Step 4 & 5)
Interventions ImplementedRisk of central line associated bloodstream infections
Make sure best practices are used for all central lines insertions.
A line cart and checklist is used for all central lines insertions.
Risk of central line associated bloodstream infections due to poor compliance with IV tubing changes
Make sure every central line IV tubing is changed according to best practice.
New IV tubing labeling system used.
Risk of medication errors Point of care pharmacist available on units
Pharmacist assigned
Poor management of pain Create guideline or protocol for pain assessment and management
Pain card at every bedside
Poor communication among ICU providers Create Short Term (Daily) Goals Sheet
Short term goals sheet used during rounds
Poor communication during ICU discharge leading to medication errors in transfer orders
Implement medication reconciliation process at ICU discharge
Medication reconciliation done at discharge
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Improve Pain ManagementImprove Pain Management
• Educate Staff
• Put visual analog pain scale (VAS) card at bedside
• Have residents report pain scores
• Define defect as pain score > 3
Erdek Pronovost
Erdek & Pronovost
© 2009
Improve Pain Assessment
0102030405060708090
100
week1
week2
week3
week4
week5
week6
week7
% with VAS
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Improve Pain Management
0102030405060708090
100
week 1 week 2 week 3 week 4 week 5
% with VAS < 3
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Step 5: Teamwork ToolsStep 5: Teamwork Tools• Daily Goals
– J Crit Care 2003;18(2):71-75
• Morning Briefing – Jt Comm J Qual Patient Saf. 2005;31(8):476-9
• Learning from Defects– Jt Comm J Qual Patient Saf. 2006;32(2):102-8– Am J Med Qual 2009;24(3):192-5.
• Team Check Up Tool – Jt Comm J Qual Patient Saf. 2008;34:619-623
• Shadowing– Jt Comm J Qual Patient Saf. 2008;34:614-8
0
10
20
30
40
50
60
70
80
90
100
% o
f res
pond
ents
with
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n IC
U re
porti
ng g
ood
team
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clim
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Teamwork Climate Across Michigan ICUs
No BSI 21%No BSI 21% No BSI 44%No BSI 44% No BSI 31% No BSI 31%
No BSI = 5 months or more w/ zeroNo 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
Health Services Research, 2006;41(4 Part II):1599.
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CUSP Lessons LearnedCUSP Lessons Learned
• Culture is local– Implement in a few units, adapt and spread– Include frontline staff on improvement team
• Not linear process– Iterative cycles– Takes time to improve culture
• Couple with clinical focus– No success improving culture alone– CUSP alone viewed as ‘soft’ – Lubricant for clinical change
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Your RoleYour Role
• Create Unit Level CUSP teams– Train all staff in the science of safety www.safercare.net– Identify hazards– Partner with senior executives– Learn from one defect per month– Try teamwork tools
© 2009
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, 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.