A Four Part Series

1. Comprehensive Unit Based Safety Program   A webinar series for QI Managers, Nurse Leaders and others supporting healthcare improvementin Wisconsin’s hospitals   July 2012

2. A Four Part Series Part I – July 10th The Science of Safety and forming the CUSP team Part II – August 7th The Staff Safety Assessment & Safety Huddles Part III – September 4th Identifying Defects Part IV – October 2nd Learning from Defects

3. Objectives for the Series • Understand what CUSP is and it’s components. • Understand how to apply CUSP components in practice. • Understand the vital importance that a patient safety focus has on a unit. • Gain access to resources related to the adoption of CUSP.

4. Who is Participating in This Series? • Any hospital enrolled in WHA’s Partners for Patients collaborative. • QI Departments planning to adopt CUSP approaches house wide • Units actively implementing CUSP Disclaimer information here…

5. Participation in the Webinar Series Levels of Participation • Level A – Learning about the CUSP model. Participants may be QI/Risk Management or Nursing staff or leaders. • Level B - Implementing the aspects of the CUSP model as well as completing webinar specific homework. Participants may include QI/Risk Managers and Nurses. • Level C – Convening a Safety Team for learning and implementing the CUSP model. (Or involving an already existing Safety Team) At a minimum, Safety Team consists of CNO, Executive, Unit Manager, Physician and staff.

6. Process for the Webinar Series • Learn content through webinar • Receive follow-up materials • Complete “next steps” from each webinar • Receive mid-month check-up tool • Intended as a reminder

7. What is CUSP?

8. The Vision of CUSP The Comprehensive Unit-based Safety Program (CUSP) 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

9. CUSP History • CUSP was started at Johns Hopkins Hospital in the 1990’s • Keystone project – Michigan initiative – 75 hospitals, 127 ICUs • In collaboration with Johns Hopkins Quality and Safety Research Group • Reduce errors and improve patient outcomes in ICUs • Combination of evidence based medicine and quality improvement • Five interventions implemented over a two year grant funded period • Still going strong!!!!

10. All Units, All the Time This is a Standardized approach NOT just for BSI. STOP CAUTI STOP FALLS STOP VAP

11. The “Secret Ingredient” is CUSP Keep focus on this throughout the journey!!! Form a unit CUSP team with executive sponsorship Measure unit culture Educate staff on Science of Safety Identify defects using the Staff Safety Assessment; prioritize defects Learn from one defect per quarter Implement team/communication tools

12. Why CUSP Works • It focuses on culture. • It integrates safety practices into daily work. • It translates. • It has easier buy-in. • It brings accountability. • It keeps leaders grounded.

13. Measuring Unit Culture

14. Getting there isn’t easy “The soft stuff is always harder than the hard stuff.” -- Richard Enrico, CEO PepsiCo, 1995

15. Why Focus on Culture? • Because culture is local, it must be targeted at the unit level, with support at the organizational level. • Frontline staff know the hazards facing their patients and are capable of identifying solutions and plans to address specific problems.

16. Safety Culture Safety Culture encompasses the attitudes held within a workplace, from the leadership to the front lines. This includes: • How open staff is to discussing patient safety issues and concerns with their colleagues and their leaders • How safe they feel about speaking out if they think that a patient is in danger • How serious they think the organizational leadership is about patient safety • How well they think they work as a team.

17. The Age-Old Question: How do we measure culture? Surveys are a simple, low cost way to (sort of) measure culture. (and it’s better than not knowing anything about your culture!)

18. Culture Assessment • Important to measure your Safety Culture • Examples include AHRQ Hospital Survey on Patient Safety Culture, Press Ganey’s Safety Culture Survey • Safety Culture survey results provide insight into frontline staff’s attitudes about patient safety within your organization. • May give some indication of staff’s actual practices around patient safety.

19. Example of a Culture of Safety Survey • AHRQ has made available the Hospital Survey on Patient Safety Culture (HSOPS) since 2004 • Comparative Data is available 2007 – 2010 • The 2010 database has 885 hospitals, and 338,607 staff responses. • On average, hospitals submitted 383 completed surveys, for a response rate of 56%.

20. Very Different from “Satisfaction” (But much more difficult to “fix”)

21. National Data Trends

22. Strengths and Areas for Improvement From the AHRQ Executive Summary

23. Wisconsin’s HSOPS Data Results to be shared during live webinar

24. What to do With the Results? • Analyze and share survey results with unit staff as well as leadership. • Many hospitals take these results to their Quality Council and/or Board of Trustees. • Use as a baseline measurement prior to implementing CUSP. • Use as a method of focusing on improvement/culture change.

25. Forming your CUSP team

26. Why Form a Team? • One person can’t change a culture. • Need a variety of perspectives. • Leaders are removed from day-to-day interactions. • Staff needs Leadership help to influence change.

27. CUSP Team • Must be unit based • If you want to understand and impact unit culture and safety the team must include front line staff • Representation from all types of staff members who provide direct patient care on a unit

28. Who to Include? • At a minimum, the following staff should be on your CUSP team: • Team Leader/Safety • Physician • Executive Champion • Staff Nurse (ideally one from each shift) • Other potential team members: • Nutritionist • Infection Preventionist • Quality Manager • Nurse Manager/Unit Leader • Pharmacist

29. Executive Partnership • Executive sponsorship is key to the success of the CUSP team. • Should be part of the CUSP team. • Does not have to have a clinical background (consider asking your CFO, COO, etc). • Executive Leadership should celebrate wins and provide encouragement, support, attention, and resources if there are set backs.

30. Educating Staff on the Science of Safety

31. Medical errors most often result from a complex interplay of multiple factors. Only rarely are they due to the carelessness or misconduct of single individuals Lucien L. Leape, MD Harvard School of Public Health

32. How Can These Errors Happen? • People are fallible • Medicine is still treated as an art, not science • Need to view the delivery of healthcare as a science • Need systems that catch mistakes before they reach the patient

33. Why Mistakes Happen? Process Factors People Factors • Fatigue • Inattention/distraction • Unfamiliar situations/new problem • Using past solutions • Equipment design flaws • Communications errors • Mislabeling/inadequate instructions • Variable input (diff pts) • Inconsistency/variation • Complexity • Too many/complicated steps • Human intervention • Tight time constraints • Hierarchical culture

34. SystemFailureLeadingtoThisError A case study: Communication between resident and nurse Inadequate training and supervision Catheter pulled with Patient sitting Lack of protocol For catheter removal Patient suffers Venous air embolism 8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004. 9. Reason J, Hobbs A., 2000.

35. System Factors Impact Safety Institutional Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Adapted from Vincent BMJ

36. How Can We Improve? Understand the Science of Safety • Every system is perfectly designed to achieve the results it gets • Understand principles of safe design • standardize, create checklists, learn when things go wrong • Recognize these principles apply to technical and team work • Teams make wise decisions when there is diverse and independent input Caregivers are not to blame

37. Principles of Safe Design • Standardize • Eliminate steps if possible • Create independent checks • Learn when things go wrong • What happened? • Why? • What did you do to reduce the risk? • How do you know it worked?

38. What Happens When We Focus on Patient Safety?

39. 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.

40. The Science of Safety Resources Webinar Follow Up Materials (will be sent out in a follow up email) • Link to Science of Safety video • CUSP Toolkit • Key messages for CUSP team sponsorship • Bedside staff • Project leaders • Executive Champion

41. The Science of Safety Homework In the next 30 days: • Decide who should be involved in a CUSP/Safety team. • Confirm a CUSP/Safety team membership and convene the team. • To educate staff, have everyone view the Science of Safety Video. • Review culture survey baseline data or conduct a culture survey. • Plan to attend Part II (The Staff Safety Assessment & Safety Huddles) webinar on August 7th for next steps.

42. The Science of Safety Check Up Mid-month Check Up Via a web survey Questionnaire sent out on July 27th • Did you convene a CUSP/Patient Safety team? • How many staff viewed the Science of Safety video? • Do you have a baseline safety culture? • Did the CUSP/Patient Safety team review the results of your hospitals most recent safety culture survey results? • Were there any areas for improvement detected? • Do you have an ongoing process (informal or formal) used to review these results?

43. Additional Resources AHRQ Safety Survey Tools: http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm CUSP Resources: http://65.23.152.3/stop-bsi/manuals-and-toolkits/ http://www.nejm.org/doi/full/10.1056/NEJMcpc1007085

44. Thank You Questions? Jill Hanson & Stephanie Sobczak Wisconsin Hospital Association