The Basics of the Comprehensive Unit-Based Patient Safety Program (CUSP)

1. The Basics of the Comprehensive Unit-Based Patient Safety Program (CUSP) People, Priorities, & Learning Together Module1 Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI patposa@comcast.net

2. The History of CUSP – Michigan Project Keystone project – Michigan initiative-75 Hospitals, 127 ICUs In Collaboration with Johns Hopkins 'Quality and Research Institute Reduce errors and improve patient outcomes in ICUs Combination of evidence based medicine and quality improvement 5 interventions implemented over a 2 year Grant funded period Still going strong after 5 years!!!!

3. Keystone: ICU • CUSP:Science of Safety • CLABSI • VAP • Daily Goals • Sepsis • Oral Care • Delirium Partnership between Johns Hopkins University and MHAInitiated with AHRQ Matching Grant Sustained with participant fees in 2005 and 2006

4. The “Secret Ingredient”Comprehensive Unit-Based Patient Safety Program • 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

5. 1. Forming a CUSP Team

6. Forming a CUSP Team • Must be unit based • If you want to understand and impact unit culture and safety the team members should include front line staff • Who should be on the team? • Those involved in delivering patient care on unit – will vary by unit type • Team Leader • Nurses—representatives from all shifts • Physician—unit medical director, residents • Pharmacist • Infection control practitioner • Nurse manager/unit leader

7. Executive Partnership • Executive should become a member of the team • Executive should review defects, ensure teams have resources to reduce risk, hold teams accountable for decreasing/improving risks • Round at least quarterly with goal of talking with at least 60% of the staff • Key Messages for Executive sponsors

8. 2. Measuring Unit Culture

9. What is a Culture? That’s not the way we do it here!!! Represents a set of shared attitudes, values, goals, practice & behaviors that makes one unit distinct from the next Pronovost, PJ et al. Clin Chest Med, 2009;30:169-179

10. Measuring Unit Culture • How to will be discussed on October’s call • HSOPS tool

11. 3. Educating Staff on the Science of Safety

12. 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

13. 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

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

15. SystemFailureLeadingtoThisError 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.

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

17. 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

18. 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 risk? • How do you know it worked?

19. 4. Identifying and Prioritizing Defects

20. Identifying Defects – Staff Safety Assessment • Two questions for bedside staff: • Please describe how you think the next patient in your unit/clinical area will be harmed • Please describe what you think can be done to prevent or minimize this harm

21. Prioritize Defects • List all defects • Discuss with staff what are the largest safety risks?

22. 5. Learning from at least one defect per quarter

23. Learn from defects/mistakes • What happened? • Why did it happen (system lenses)? • What could I do to reduce the risk? • How do you know the risk was reduced? • Create policy/process/procedure • Ensure staff know policy/process or procedure • Evaluate if change has occurred Will spend sessions 3 and 4 on Learning from Defects

24. 6. Implement Team and Communication Tools

25. Tools and strategies to improve safety and teamwork • Daily rounds/goals • Pre-procedure briefing • Morning briefing • Huddles • Learn from a defect

26. So what happens when we focus on patient safety ??? (culture and teamwork)

27. Teamwork Climate Across Michigan ICUs % of respondents within an ICU reporting good teamwork climate

28. Safety Climate Across Michigan ICUs % of respondents within an ICU reporting good safety climate

29. 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

31. Results • Lives Saved – 1,729* • Patient Days Saved – in excess of127,000* • Dollars Saved – 0ver $246 Million* • Culture of Safety improved 28% • Teamwork improved 15% * Based on the Johns Hopkins Opportunity Calculator

32. "Needs Improvement“ Statewide Michigan CUSP ICU Results • Less than 60% of respondents reporting good safety or teamwork climate =“needs improvement” • Statewide in 2004 84% needed improvement, in 2006 41% • Non-teaching and Faith-based ICUs improved the most • Safety Climate item that drives improvement: “I am encouraged by my colleagues to report any patient safety concerns I may have”

33. ICU Teamwork Climate 2004-2008

34. ICU Safety Climate 2004 - 2008

35. Module 1: The Basics of CUSP • Session 1: Forming a CUSP team and Science of Safety Education • Session 2: Staff Safety Assessment and Measuring Culture • Session 3: Learning from a Defect-part 1 • Session 4: Learning from a Defect-part 2 • Session 5: Safety Culture Results and Action Planning • Session 6: Evidence-based Practice, Just Culture and CUSP team tools

36. What are your next steps? • Set up your CUSP team • Calendar out 6 months of team meetings • Recruit an executive • Listen to physician engagement call • If team set up, educate team on the Science of Safety, establish plan on how to roll out to unit staff

37. Be Couragous We all are responsible for the safety of our patients----Own the issues • “If not this, then what??” • “If not now, then when?” • “If not us, then who??”

38. Notes on Hospitals: 1859 “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.” Florence Nightingale Advocacy = Safety

39. A Healthcare Imperative “In medicine, as in any profession, we must grapple with systems, resources, circumstances, people-and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, we must improve.” AtulGawande in his book, Better: A Surgeon’s Notes on Performance

40. Questions?