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

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.


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?


Ensure Patients Reliably Receive Evidence

Pronovost: Health Services Research, 2006


What is CUSP?

• Comprehensive Unit-based Safety Program• An intervention to learn from mistakes and

improve safety culture for sustained improved patient outcomes


Safety/Quality Improvement Is A Two Part Process


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


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


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.


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


Prioritize Defects

• List all defects, area for improvement

• Discuss with staff what are the three greatest risks


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


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


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


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


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


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


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


CUSP Model


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


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.


CUSP: Stop HAI Web Site

• Tools, Education , Resources• http://www.onthecuspstophai.org.


CONTACT INFORMATION

Denise Flook

[email protected].

770-249-4518

Documents

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