Armstrong Institute for Patient Safety and Quality

1. CUSP for Safe Surgery: The Surgical Unit-Based Safety Program Project Overview Armstrong Institute for Patient Safety and Quality

2. Learning Objectives • Understand the magnitude of preventable harm • Identify SUSP program • Project goals and interventions • Participation requirements and timeline • Describe steps to enroll in SUSP

3. The Problem is Large • In U.S. Healthcare system • 7% of patients suffer a medication error 2 • On average, every patient admitted to ICU suffers adverse event 3,4 • 44,000- 98,000 people die in hospitals each year as the result of medical errors 5 • Nearly 100,000 deaths from HAIs 6 • Estimated 30,000 to 62,000 deaths from CLABSIs 7 • Cost of HAIs is $28-33 billion 7 • 8 countries report similar findings to the U.S. 2. Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995 3. Donchin Y, Gopher D, et al., Crit Care Med, 1995. 4. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997. 5. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999. 6. Klevens M, Edwards J, Richards C, et al., PHR, 2007 7. Ending Health Care-Associated Infections, AHRQ, 2009. Armstrong Institute for Patient Safety and Quality

4. Preventable Harm • 230 million surgeries / yr worldwide • More common than births ( 36 million / yr) • 1 in 25 people • 25% in-patient surgeries followed by complication • 7 million disabling complications / yr • 0.5 – 5% deaths following surgery • 1 million deaths / yr • 50% of all hospital adverse events linked to surgery • At least 50% of adverse surgical events are avoidable http://www.who.int/patientsafety/challenge/safe.surgery/en/

5. Surgical Care Improvement Project (SCIP) CMS National Impact Assessment of Medicare Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NationalImpactAssessmentofQualityMeasuresFINAL.PDF. March 2012; 42.

6. SUSP Project Overview

7. SUSP Project Overview • AHRQ funding project • Individual hospitals participate for 2 years • Leveraging leaders in field • Armstrong Institute, ACS NSQIP, AHRQ, University of Pennsylvania, WHO • All hospitals in any state, as well as hospitals in the District of Columbia and Puerto Rico are encouraged to participate. Armstrong Institute for Patient Safety and Quality

8. SUSP Enrollment(as of Nov 2012) • Cohort 1 (July 2012) • 11 hospitals • 3 Coordinating Entities (FL, CO, TN) & University of Washington • Cohort 2 (started Sept 2012) • 104 hospitals • 11 Coordinating Entities (AR, CO, CT, FL, HI, IO, MI, NSN, NV, AI, TN) • Cohort 3: will start Feb 2013 • Cohort 4: TBD Armstrong Institute for Patient Safety and Quality

9. Project Goals • To achieve significant reductions in surgical site infection and surgical complication rates • To achieve significant improvements in safety culture

10. How will we get there? Reducing Surgical Site Infections Translating Evidence Into Practice (TRiP) Comprehensive Unit based Safety Program (CUSP) • Emerging Evidence • Local Opportunities to Improve • Collaborative learning • Summarize the evidence • 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 Technical Work Adaptive Work http://www.hopkinsmedicine.org/armstrong_institute

11. Successful Efforts to Reduce Preventable Harm • Michigan Keystone ICU program • Reductions in central line-associated blood stream infections (CLABSI)1,2 • Reductions in ventilator-associated pneumonias (VAP) 3 • National On the CUSP: Stop BSI program 4 • N Engl J Med 2006;355:2725-32. • BMJ 2010;340:c309. • Infect Control Hosp Epidemiol. 2011;32(4): 305-314. • www.onthecuspstophai.org

12. Percent of Units with Zero CLABSIs and Achieving Project Goal (<1/1000 CL days) *Data drawn from Interim Project Report – Figure 5 – Cohorts 1 through 3 www.onthecuspstophai.org

13. Advancing the Science • Harm is preventable • Many healthcare acquired infection and complications are preventable; should be viewed as defect • Technical and adaptive work • Focus on systems; Not individuals • Engaging frontline staffto identify and fix local opportunities to improve • Framing as social problem that can be solved • Clinical communities

14. Wrong-patient, Wrong-site, Wrong-procedure Events Reviewed by The Joint Commission The Joint Commission, Sentinel Event Data; http://www.jointcommission.org/assets/1/18/Event_Type_Year_1995-2011.pdf;29.

15. How is SUSP different? • Informed by science • Led by clinicians and supported by management • Guided by measures Armstrong Institute for Patient Safety and Quality

16. SUSP Interventions

17. SUSP Interventions •  No single SSI prevention bundle • Deeper dive into SCIP measures to identify local defects • Emerging evidence • Bowel Prep • Antibiotic redosing • Alcohol based skin prep  • Capitalize on frontline wisdom to identify local opportunities to improve • CUSP/Staff Safety Assessment Armstrong Institute for Patient Safety and Quality

18. Comprehensive Unit-based Safety Program (CUSP) • Educate staff on science of safety • Identify defects • Assign executive to adopt unit • Learn from one defect per quarter • Implement teamwork tools Jt Comm J Qual Patient Saf 2010;36:252-60 Resources: http://www.ahrq.gov/cusptoolkit/

19. SUSP Interventions • Implement WHO briefings / debriefings • Growing body of evidence to support use • Adapt to local environment • Tools focused on SSI Prevention • SSI Investigation, Skin Prep Audit, • Antibiotic Audit, Normothermia Audit and others • Additional interventions will be provided that teams may choose to implement, including but not limited to activities to reduce mislabeled specimens, wrong sided surgery, and retained foreign objects Armstrong Institute for Patient Safety and Quality

20. Potential benefits • National effort led by clinicians • Shared learning • We will learn from each other • Advancing science together • Building relationships in surgical community that will last beyond the project • Cutting edges tools and resources including ethnographic studies and platform that links data collection, reporting, and training with social networking to improve communication and sharing Armstrong Institute for Patient Safety and Quality

21. https://armstrongresearch.hopkinsmedicine.org/susp.aspx

22. What do teams need to do? • Assemble a multidisciplinary team • Including Preop, OR and Postop staff • Participate in 6 weekly on-boarding webinars • Participate on monthly content webinars • Participate on monthly coaching webinars • All webinars recorded and archived online • Participate in annual face-to-face meetings • Regularly meet as a team to implement interventions and monitor performance Armstrong Institute for Patient Safety and Quality

23. What data will teams need to collect?* • Monthly SSI data for colorectal and general surgery patients • Numerator and denominator • Quarterly project implementation data • Structured interview and brief survey • Annual teamwork/culture data using the AHRQ Hospital Survey of Patient Safety (HSOPS) • Other complications from ACS NSQIP as program evolves  • Will work with HENS to ensure data reporting meets their needs *If data is already collected/available (ie: ACS NSQIP or NHSN), we will work with your team to import if you desire Armstrong Institute for Patient Safety and Quality

24. Timeline • Months 1-3: Planning and preparation • Participate in Immersion calls* • Identify CUSP team members (OR with representation from PACU and Floor) including executive leadership • Administer culture survey to all perioperative staff (OR, PACU, Floor) • Initial Roll Out: Months 4-6 • Educate on science of safety • Conduct staff safety assessment (OR, PACU, Floor focus) • Conduct culture checkup • Feedback and benchmarking results of HSOPS survey • Initiate SSI Prevention Activities: Explore opportunities to ‘deep dive’ into SCIP measures and emerging SSI prevention interventions. Armstrong Institute for Patient Safety and Quality

25. Timeline • Months 7- 9 • Implement Learning from Defects Tool I • Implement briefings, building on WHO checklist to address defects • Continue SSI Prevention Activities • Optional tools including Investigating an Infection Tool, Skin Prep Audit Tool, SSI prevention activity audits, teamwork tools (based in TeamSTEPPS) and patient education related tools • Months 10-12 • Implement debriefings, building on WHO checklist as tool to address defects (OR activity) • Continue SSI Prevention Activities and expand to new topics. • Optional tools including Handoff Tools, Shadowing tool, teamwork assessment & learning from a communication failure Armstrong Institute for Patient Safety and Quality

26. Timeline • Months 13-24 • This project will continue for an additional 6 to 12 months after the end of Year 1. • Expand efforts • To improve technical work (e.g., DVT/PE, Wrong sided surgery, retained foreign objects • To Improve teamwork, communication, and culture (e.g., additional aspects of teamwork training) Armstrong Institute for Patient Safety and Quality

27. Challenges • Engaging frontline staff • Staff time (2-4 hr/week for each RN, surgeon, anesthesia, team leader, infection preventionist) • CUSP executivepartnership • Data collection burden • Often no forum for joint learning • Need to learn together • Many examples of success Armstrong Institute for Patient Safety and Quality

28. JHU Colorectal CUSP • Standardization of skin preparation • Preoperative chlorhexidine showers • Selective elimination of mechanical bowel preparation • Warming of patients in the pre anesthesia area • Enhanced sterile techniques for bowel and skin portions of the case • Addressing lapses in prophylactic antibiotics J Am CollSurg 2012;215(2):193-200. Armstrong Institute for Patient Safety and Quality

29. JHU Colorectal CUSP *p<0.05 J Am Coll Surg 2012;215(2):193-200. Armstrong Institute for Patient Safety and Quality

30. On-boarding Call Evaluation We want to ensure that the on-boarding calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link: • https://www.research.net/s/susp_cohort_3 If you are not able to reach the link from the slide, please cut & past the URL into your browser. Armstrong Institute for Patient Safety and Quality