Comprehensive Unit Safety Program (CUSP)

David Thompson DNSc, MS, RNKristina Weeks, MHS, DrPh(c)

Teamwork Tools

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Steps 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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You got a problem, we’ve got an app for that

• https://armstrongresearch.hopkinsmedicine.org/csts/cusp/resources.aspx

Learning from Defects

Joint Commission Journal Quality & Safety Feb 2006

• What happened?• Why?• What will you do to reduce probability that it

will happen again?• How do you know risk is reduced?• Share your learning throughout organization

Learning

• Invite all who touch process to attend• Learn deeply from smaller number, rather

than “re-educate” staff on a large number• Learn at different levels

– System/hospital: one per quarter– Department: one per quarter– Nursing unit: one per month

• Share your learning throughout organization

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Familiarity with others is a critical component of effective teamwork:

• 74% of all commercial aviation accidents happen on the first day of a team flying together

• Familiarity trumps fatigue• Highlights the importance of predictable

patterns of behavior

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Intensive Care Unit (ICU) and Inpatient unitsDaily Goals

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Background

• Communication defects common• People and organizations who create explicit

goals achieve more than those who do not• Rounds generally patient rather than provider

centered

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ICU Physicians and ICU RN Collaboration

51%

88%

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60

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K P L &D

RN rates ICU Physician ICU Physician rates RN

% o

f res

pond

ents

repo

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abo

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dequ

ate

team

work

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Percent Understanding Patient Care Goals

00.10.20.30.40.50.60.70.80.9

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1 2 3 4 5 6

ResidentsNurses

Implemented patientgoals sheet

J Crit Care 2003,18, 71-75

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Impact on ICU Length of Stay

0

0.5

1

1.5

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2.5

Avg

. LO

S (d

ays)

ICU LOS

Daily Goals

654 New Admissions: 7 Million Additional Revenue

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Thoughts for Daily Goals

• Leading question: Why is patient in ICU?• Save teaching for a separate session (avoid

pontification)• Fellow/resident wrote note on each patient

daily before attending reached patient for rounds – need to summarize this and convert into the work for the patient

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How to use daily goals form?

• Be explicit• Ask the Important questions

– What needs to be done for discharge– Safety risk– Scheduled labs

• Completed on rounds• Stays with bedside nurse• Modify to fit your hospital

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Conducting a Morning Briefing (ICU)Conducting a Morning Huddle (OR)

Improving Situational Awareness by

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Situation AwarenessAn Overview

• Members of the team have and understanding of “what’s going on” and “what is likely to happen next”

• Teams are alert to developing situations, sensitive to cues and aware of their implications.

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Briefing Defined

What a Briefing immediately does? 1. Map out the plan of care. 2. Identify Roles and Responsibilities for each team

member.3. Heightens awareness of the situation. 4. Allows the team to plan for the unexpected.5. Team members needs, and expectations are met.

A briefing is a discussion between two or more people, often a team, using succinct information

pertinent to an event.

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Morning Briefing Process

Three simple questions1. What happened overnight that I need to

know about? 2. Where should I begin rounds? 3. Do you anticipate any potential defects

in the day?

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What happened overnight that I need to know about?

• You should be thinking about…Was there adequate coverage?

• Were there any equipment issues?• Were cases posted to the ICU?• Unexpected changes in patient acuity?• Were there any adverse events?

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Where Should Rounds Begin?

1. Is there a patient who requires my immediate attention secondary to acuity?

2. Which patients do you believe will be transferring out of the unit today?

3. Who has discharge orders written?

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As you continue planning rounds

4. How many admissions are planned today?5. What time is the first admission?6. How many open beds do we have?7. Are there any patient having problems on an

inpatient unit?

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Do you anticipate any potential defects in the day?

• Patient scheduling• Equipment availability/ problems• Outside Patient testing/Road trips• Physician or nurse staffing• Provider skill mix

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Shadowing another Provider

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Why do we need to Follow?

To gain perspective of the other providers• Practice, • Responsibilities, • Work environment,To identify issues that effect teamwork and

communication that may impact patient care and patient outcomes.

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Who should have this experience?

• Patient care areas as part of the Comprehensive Unit Based Safety Program (CUSP)

• When there is a difference of > 20% in SAQ scores between provider types.

• As part of orientation to a new unit• Units with little collaboration between

disciplines.

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Preparing to Follow

• Review the tool prior to your shadowing experience

• Follow your health care provider through their daily activities.

• Review your list of communication and teamwork problems

• Discuss with the Provider• Make a plan for resolution

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Our Findings

• Handoffs for 4 hour shifts not thorough, increased opportunity to forget key details as this increased the total number of people…

• Physician consults usually obtained but not always read by the requesting team…

• Nurse often most informed team member on the patient’s plan of care but does not always speaks up

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A fly on the WallObserving Rounds

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Observe and don’t participate

• A method to add structure to interdisciplinary rounds.

• Improve collaboration and identify communication defects.

• Can be done by any discipline.• Should be debriefed with the team

afterwards.

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Setting priorities for improving the culture in your unit.

Culture Check up Tool

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Prioritize your weak areas

• Pick the 3 lowest values from you HSOPS• Identify a plan to address those areas where

improvement is needed. • Remember you are looking to improve your

scores to the 75 percentile.• Implement your strategy and reassess after

the next HSOPS survey.

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Questions?