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Small Rural/CAH Learning Community MeetingMay 23, 2012
Denise Flook, RN, MPH, CIC HAI Collaborative Lead
Vice President, Infection Prevention/Staff Engagement
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.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.
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.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?
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Ensure Patients Reliably Receive Evidence
Pronovost: Health Services Research, 2006
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What is CUSP?
• Comprehensive Unit-based Safety Program• An intervention to learn from mistakes and
improve safety culture for sustained improved patient outcomes
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.Going.
Safety/Quality Improvement Is A Two Part Process
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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
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.Going.
The CUSP Steps
1. Educate 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
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.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.
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.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
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Prioritize Defects
• List all defects, area for improvement
• Discuss with staff what are the three greatest risks
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.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
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.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
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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
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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
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.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
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.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
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Other Improvement ToolsOther 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
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.Going.
CUSP Model
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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
• More details are in the CUSP manual
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.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.
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.Going.
CUSP: Stop HAI Web Site
• Tools, Education , Resources• http://www.onthecuspstophai.org.
Learn. Act. Improve. Spread.Learn. Act. Improve. Spread. Keep the Drum Beat Keep the Drum Beat Going.Going.
CONTACT INFORMATION
Denise Flook
dflook@gha.org.
770-249-4518
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