Cardiac Surgery CER Project: The Comprehensive Unit Based Safety Program (CUSP)

1. Cardiac Surgery CER Project:The Comprehensive Unit Based Safety Program (CUSP) An Interventionto Learnfrom Mistakesand Improve Safety Culture Chris Goeschel cgoesch1@jhmi.edu

2. Immersion call Schedule

3. Learning Objectives • To explain the philosophy and approach of CUSP • To describe the steps in CUSP • To introduce teamwork tools that help improve safety

4. What is CUSP? • Comprehensive Unit-based Safety Program • An Intervention to Learn from Mistakes and Improve Safety Culture

5. The 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

6. The QSRG Model to Improve Care Central line AssociatedBloodstreamInfections(CLABSI) Translating Evidence Into Practice (TRiP) Comprehensive Unit based Safety Program (CUSP) Wash your hands prior to procedure Clean insertion site with chlorhexidine Use full barrier precautions Avoid the femoral site Ask every day if lines can be removed • Summarize the evidence in a checklist • Identify local barriers to implementation • Measure performance • Ensure all patients get the evidence • Engage • Educate • Execute • Evaluate Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools www.safercare.net

7. The QSRG Model to Improve Care Reducing Surgical Site Infections Translating Evidence Into Practice (TRiP) Comprehensive Unit based Safety Program (CUSP) • Summarize the evidence in a checklist • Identify local barriers to implementation • Measure performance • Ensure all patients get the evidence • Engage • Educate • Execute • Evaluate Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools www.safercare.net

8. The QSRG Model to Improve Care Reducing Ventilator Associated Pneumonia Translating Evidence Into Practice (TRiP) Comprehensive Unit based Safety Program (CUSP) • Summarize the evidence in a checklist • Identify local barriers to implementation • Measure performance • Ensure all patients get the evidence • Engage • Educate • Execute • Evaluate Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools www.safercare.net

9. Pre 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

10. Steps of CUSP • 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 • Implement teamwork tools Pronovost J, Patient Safety, 2005

11. 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.safercare.net/OTCSBSI/Staff_Training/Entries/2009/9/6_1._The_Science_of_Improving_Patient_Safety.html

12. Step 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

13. Complete the Staff Safety Assessment Step 2: Identify Defects

14. Staff Safety Assessment Results N=24* *2 answered unit is safe

15. Prioritize Defects • List all defects • Discuss with staff what are the three greatest risks • Use Learning from Defect Tool to guide your efforts

16. Step 3: Executive Partnership • 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)

17. Step 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

18. Step 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 ? • Create policy / process / procedure • Ensure staff know policy • Evaluate if policy is used correctly Pronovost 2005 JCJQI

19. 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;

20. 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;

21. 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

22. 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

23. Rank Order of Error Reduction Strategies Most Effective Forcing functions and constraints Automation and computerization Standardization and protocols Checklists and double check systems Rules and policies Education / Information Least effective Be more careful, be vigilant

24. 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

25. 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)

27. Improve 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

28. Improve Pain Assessment

29. Improve Pain Management

30. Step 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

31. No BSI = 5 months or more w/ zero No BSI 21% No BSI 44% No BSI 31% Teamwork Climate Across Michigan ICUs The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care % of respondents within an ICU reporting good teamwork climate Health Services Research, 2006;41(4 Part II):1599.

32. CUSP 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

33. Your 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 33

34. 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.