Our Story of CUSP Implementation Mary Fine, RNBC, QMHP, SANE

1. Our Story of CUSP ImplementationMary Fine, RNBC, QMHP, SANE

2. Ozarks Medical Center 114 bed community hospital with 21 outlying clinics ICU CUSP team 2N (surgical inpatient unit) CUSP team 7 nursing units implemented CUSP communication and teamwork tools Beginning an Outpatient Surgery/GI CUSP team

3. Marcia Robson, CNO Staff nurse on Medical-Surgical floor House Supervisor Interim DON Nurse Manager of OB Director of Women’s services, ES, Dietary, ED, Sleep lab, Lab, OR, and Cath Lab Chief Nursing Officer Our First Executive sponsor

4. Sponsor responsibilities Participates in kick off Conducts Rounding Monitors Progress of Learning from defect tools Keeps lines of communication open with physicians Obtains resources to mitigate hazards Participates with rewards and recognitions

5. Ozarks Medical Center:Learning from Defects (LFD) 4 ICU Physician orders post surgery Communication between floors with transfers CLABSI

6. Ozarks Medical Center:Learning from Defects (LFD) 2 North (Surgical Floor) Falls Medication errors Communication with antibiotics CAUTI

7. CAUTIs per 1000 Patient Days

8. Reward and Recognition

10. Considerations for who Who “owns” the department implementing the CUSP team? Do you have a “driver and shaker”? Is there someone passionate for quality and safety? Who is the influencer?

11. Suggestions if struggling CASE STUDY– show increase LOS and cost associated to event Patient feedback from survey results Show impact on re-imbursement Conduct an internal culture of safety survey Start small and show results Tie the request back to the organization culture

12. Lessons Learned Frontline staff are the key to success Frontline staff love to see results Have a structured format for CUSP kick off Share the WINS with administration

13. Sustaining Results ACCOUNTABILITY

14. OMC’s next steps Implement Surgery/GI CUSP team Jeannie Looper, COO is executive sponsor IMPLEMENT MORE TEAMS Keep the ball rolling