On the CUSP: Stop BSI

On the CUSP: Stop BSI The Comprehensive Unit-based Safety Program (CUSP)

The Vision of CUSP The Comprehensive Unit-based Safety Program is a safety culture program 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

CUSP: 5 Steps • Educate staff on science of safety • Identify defects • Assign executive to adopt unit • Learn from one defect per quarter • Implement teamwork tools Pronovost J, Patient Safety, 2005 CUSP Toolkit, http://www.safercare.net/OTCSBSI/Resources.html

Working the Steps in CUSP One Cycle of CUSP From Start to Finish: A Telemetry Unit

Step 1: Educate • All staff were educated on the Science of Safety • Included nurses, technicians, clerical associates, and housekeeping. • All physicians are educated upon hire • All nurses are educated upon hire.

All staff were asked to complete the Staff Safety Assessment (Appendix C) Step 2: Identify Defects

Step 3: Executive Adopts a Unit • The VP of Security and Parking is the executive for this unit. • The Executive along with the CUSP team reviewed the Staff Safety Assessment to identify select a defect to work on and learn from.

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

Staff Safety Assessment Results • Staff had many ideas about how to reduce the falls on this unit. 23 interventions involving: • Bed • Side rails • Patient • Environment • Education • Process changes • Communication

Step 4: Learning from Defects The next CUSP meeting the team started the Learning from Defects tool (Appendix G).

Step 4: Learning from Defects • To answer section I the team needed to understand if there were any common themes/risk factors related to the falls on this unit. • Reviewed 12 months of fall data: • 90% of falls occurred on night shift, within 1 hour of change of shift, and on weekends • Nurses reported they had forgotten to turn bed alarm back on after giving care. • Less nurses/staff around seemed to predict increased risk for fall or day shift could compensate for bed alarms off when they had more staff around

Step 4: Learning from Defects n/a n/a

Step 4: Learning from Defects Team factor- adequate communication during care w/ ancillary staff 5 5 Caregiver factor- distractions lead to patients bed alarm not turned on 5 5

Step 4: Learning from Defects Independent double check for bed alarms Add column to report sheet for patients with high fall risk 5 5 Every 4 hours staff will check Hill-Rom system to ensure bed alarms are on 5 4

Step 4: Learning from Defects Add column to report sheet to communicate high fall risk to ancillary staff Rosemary 9/15/09 Develop checklist to allow staff to document that bed alarm on every 4 hours* Stacey 9/15/09 *Timed with shift change- 02:00, 06:45, 14:45, 18:45, 22:45 - Clerical associate responsible for checking at all times except 02:00 - Charge RN responsible for 02:00 check

Step 4: Learning from Defects

Engage & Educate Started engaging and educating staff as soon as falls identified as defect to work on for CUSP project.

Step 4: Learning from Defects Engage & Educate Evaluate NDNQI 10th Percentile

Step 4: Learning from Defects Evaluate: • 7 months prior to intervention Mean - 2.85 falls per 1,000 patient days • 7 months since the intervention Mean - 1.33 falls per 1,000 patient days • 50% reduction in falls • Extremely low burden intervention

Examples of CUSP in Action!!!

CUSP is a Continuous Journey • CUSP is a marathon not a sprint • Ask staff at least every six months how the next patient is going to be harmed and invest the time and resources to reduce this harm • Learn from one defect per quarter and share lessons learned • Implement teamwork tools that best meet the teams needs

On the CUSP: Stop BSI