Comprehensive Unit-Based Safety
Program (CUSP)
Central Line Associated Blood Stream
Infections
Terri Conner, Ph.D.
Nybeck Analytics
Partnership for Patients Initiative at
Texas Center for Quality & Patient Safety
GOALS

Work to eliminate central-line associated
blood stream infections (CLABSI) in your unit

Improve safety culture

Learn from defects
EVIDENCE-BASED BEHAVIORS TO
PREVENT CLABSI

Remove unnecessary lines

Wash hands prior to procedure

Use maximal barrier precautions

Clean skin with chlorhexidine

Avoid femoral lines
4E’S TO ENSURING PATIENTS
RECEIVE EVIDENCE




Engage
– How does this make the world a better place?
Educate
– What do we need to know?
Execute
– What do we need to do?
– What keeps me from doing it?
– How can we do it with our resources and culture?
Evaluate
– How do we know we improved safety?
ENGAGE

CLABSIs associated with significant
morbidity, mortality, and costs

Patients in ICUs are at an increased risk
–
–
–
48% of ICU patients have indwelling central
venous catheters
15 million central line days per year in United
States ICUs
As many as 28,000 ICU patients die from
CLABSIs annually in the U.S. alone.
ENGAGE

Share about a patient who was infected

Post baseline rates of infections

Estimate number of deaths and dollars from
current infection rates

Remind staff that most CLABSI are
preventable
EDUCATE

Conduct in-service regarding CLABSI prevention

Create forum to jointly educate physicians and
nurses

Add CLABSI prevention to ICU orientation

Give staff fact sheets, articles, and slides of
evidence
EXECUTE

Standardize and reduce complexity: Create line cart

Create independent checks: Create BSI checklist

Ask providers daily whether catheters could be removed

Empower nurses to ensure physicians comply with checklist
–

Nurses can stop takeoff
Learn from mistakes: review every infection
EVALUATE

Monitor rates of infections using CDC
definitions

Post rates of infections per year in the unit

Post number of weeks or months without an
infection
CUSP
Comprehensive Unit-based Safety Program
An intervention to learn from mistakes and
improve safety culture
A good approach whenever there is a gap
between evidence-based practice and current
practice on your unit.
CUSP: EMPHASIS ON CULTURE

Shared attitudes, values, goals, practices,
behaviors

Culture influences behavior
–
Participation in quality improvement efforts
–
Communication

Breakdown in communication contributes to nearly all
adverse events.
CUSP: COMPREHENSIVE UNITBASED SAFETY PROGRAM

Safety practices part of daily work

Implemented at the unit level

Led by clinicians

Structured program, yet flexible
PRE-CUSP STEPS

Assemble Safety Team
–
Multidisciplinary
–
Different levels of experience
–
Encourage joining team at any phase of the
program
PRE-CUSP STEPS

Team Members
–
–
–
–
–
–
–
Project Leader (Unit Champion)
Nurse Manager
Physician Champion
Senior Hospital Executive
Patient Safety Coordinator
Epidemiology / Infection Control
Coach
PRE-CUSP STEPS

Measure Safety Culture
–
Before CUSP implementation, and then every 12-18 months
–
Use AHRQ’s The Hospital Survey on Patient Safety Culture
(HSOPS)
–
All clinical and non-clinical providers
–
Report results to the unit and senior hospital executive
CUSP STEPS
1.
Science of safety training
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from defects
5.
Implement teamwork tools
STEP 1: SCIENCE OF SAFETY
TRAINING

Goals
–
Magnitude of patient safety problem
–
Foundation for investigating safety defects
–
Providers’ involvement significantly affects patient
safety
STEP 1: SCIENCE OF SAFETY
TRAINING

Learning Objectives
–
Safety is a property of the system
–
Use strategies to improve system performance

Standardize work

Create independent checks for key processes

Learn from mistakes
–
Apply strategies to both technical work and team work
–
Teams make wise decisions with diverse and independent
input
STEP 1: SCIENCE OF SAFETY
TRAINING

Training Session
–
3-part “Improving Safety” presentation by Dr. Peter
Pronovost



–
Part 1: http://www.youtube.com/watch?v=GOJJHHm7lnM
Part 2 http://www.youtube.com/watch?v=wpzb7nM6oFQ&feature=rela
ted
Part 3 http://www.youtube.com/watch?v=6BnXs4KtER8&feature=relat
ed
Instruct staff on reporting of safety concerns
STEP 2: IDENTIFY DEFECTS

Eyes and ears of patient safety

Ongoing process

Disseminate Staff Safety Assessment Form

Combine results and prioritize defects
WHAT IS A DEFECT?
Anything you do not want to have happen
again.
Blood stream infections are almost always
preventable. They should be viewed as
defects.
STEP 2: IDENTIFY DEFECTS

Staff Safety Assessment Form
–
Purpose: Tap into your knowledge and experiences at the
frontlines of patient care to find out what risks are present
on your unit that do or could jeopardize patient safety.
–
All health care providers in the unit complete this form.
–
2-item questionnaire
STEP 2: IDENTIFY DEFECTS

Staff Safety Assessment Form
1.
Please describe how you think the next patient in
your unit/clinical area will be harmed.
2.
Please describe what you think can be done to
prevent or minimize this harm.
STEP 2: IDENTIFY DEFECTS

Combine Results
–
–
Group into common types of defects

Communication

Medication process

Patient falls

Supplies
Frequency distributions

Example: communication, 57%
STEP 2: IDENTIFY DEFECTS

Prioritize safety concerns
–
Obtain input from CUSP team senior executive
–
Prioritize based on

Likelihood of causing patient harm

Severity of harm

How common is the problem

Likelihood it can be solved by implementing a daily work
process
STEP 4: LEARN FROM DEFECTS
Four Key Questions
1.
What happened?
2.
Why did it happen?
3.
What will you do to reduce the chance it will
recur?
4.
How do you know that you reduced the risk that
it will happen again?
WHAT HAPPENED?

Reconstruct the timeline and explain what happened

Put yourself in the place of those involved, in the middle of the
event as it was unfolding

Try to understand what they were thinking and the reasoning
behind their actions/decisions

Try to view the world as they did when the event occurred
WHY DID IT HAPPEN?
SYSTEM FAILURES

Arise from managerial and organizational
decisions that shape working conditions

Often results from production pressures

Damaging consequences may not be evident
until a “triggering event” occurs

Develop lenses to see the system factors that
lead to the event
WHAT WILL YOU DO TO REDUCE
THE RISK OF IT HAPPENING AGAIN?

Prioritize most important contributing factors

Prioritize most beneficial interventions

Safe design principles

–
Standardize what we do
–
Create independent check
–
Make it visible
Safe design applies to technical and team work
WHAT WILL YOU DO TO REDUCE
THE RISK OF IT HAPPENING AGAIN?

Develop list of interventions

For each intervention:
–
Rate how well the intervention solves the problem or
mitigates the contributing factors for the accident
–
Rate the team belief that the intervention will be
implemented and executed as intended

Select top interventions (2 to 5) and develop intervention plan
–
Assign person, task follow-up date
HOW DO YOU KNOW RISKS WERE
REDUCED?

Did you create a policy or procedure?

Do staff know about policy or procedure?

Are staff using the procedure as intended?
–

Behavior observations, audits
Do staff believe risks were reduced?
STEP 4: LEARN FROM DEFECTS

Summarize and Share Findings
–
Learning from Defects Tool

–
–
Detailed form for each incident or identified defect
Case Summary Form

Summarize the case

Identify system failures

Identify opportunities for improvement

List actions taken to prevent future harm
Share your findings
EXAMPLES
Defect: Nasoduodenal tube placed in lung
Intervention: Protocol developed for NDT placement
Defect: Bronchoscopy cart missing equipment
Intervention: Checklist developed for stocking cart
Defect: Inconsistent use of Daily Goals rounding tool.
Intervention: Gained consensus on required elements of Daily
Goals rounding tool.
STEP 4: LEARNING FROM
DEFECTS
Key Points
–
Focus on systems, not people
–
Prioritize
–
Go mile deep and inch wide, rather than mile wise and inch
deep
–
Pilot test
–
Learn from 1 defect a quarter
–
Answer the four questions
STEP 5: TEAM WORK TOOLS
Staff Safety Assessment
Safety Issues Worksheet
Status of Safety Issues
Learning from Defects Tool
Case Summary Form
Daily Goals Checklist
Morning Briefing Tool
Shadowing Another Professional
Observing Rounds
STAFF SAFETY ASSESSMENT
Used to identify defects in the unit
1.Please
describe how you think the next
patient in your unit/clinical area will be harmed.
2.Please
describe what you think can be done
to prevent or minimize this harm.
SAFETY ISSUES WORKSHEET
Identified Issue
1.
2.
3.
Potential/
Recommended
Solution
Resourc
es
Needed
Resources
Not
Needed
STATUS OF SAFETY ISSUES
New and Ongoing
Date
Date
Safety Issue
Safety Issue
Contact
New and Ongoing
Contact
Status
Status
Goal
Goal
Completed
Date
Safety Issue
Contact
Status
Goal
LEARNING FROM DEFECTS






Explain what happened.
Check off the factors that negatively or positively contributed to the
incident.
Describe how you will reduce the likelihood of this defect happening
again by completing the tables.
Develop interventions, and choose 2-5 to implement.
– What will be done?
– Who will lead the intervention?
– When is follow-up?
Describe how you know you have reduced the risk.
Summarize your findings using the Case Summary Form.
CASE SUMMARY FORM
Form Sections
Safety tips
Case
summary
System
failures
Opportunities
Actions
for improvement
taken to prevent harm
DAILY GOALS CHECKLIST





Care plan for patients
Lists needs for the day to safely move a
patient closer to discharge
Used to improve communication among care
team members and family members.
Use during morning and evening rounds, and
kept at patient’s bedside.
Adapt to your own unit’s environment.
MORNING BRIEFING TOOL



Structured approach to assist physicians and charge nurses in
identifying the problems that occurred during the night and
potential problems during the clinical day.
Tool used by:
– Physicians who conduct patient rounds
– Charge nurses and nurse managers who make patient
assignments
Complete this tool daily prior to starting patient care rounds by
meeting with the charge nurse.
SHADOWING ANOTHER
PROFESSIONAL



Designed to provide a structured approach to identify communication,
collaboration and teamwork defects among different practice domains.
Purpose: to improve teamwork, collaboration, and communication that
affect patient care delivery
Who should use this tool?
–
Anyone on the CUSP team
–
Staff unfamiliar with responsibilities and practice domains of
another profession
–

Executive team member may want to shadow practitioners
Recommended when <60% of unit members report good teamwork or
good safety climate.
OBSERVING ROUNDS


Purpose: Provide a structured approach for improving teamwork, and
communication behaviors across and between disciplines that
negatively affect staff morale and patient care delivery.
Who Should Use this Tool?
– Physicians who conduct patient rounds.
– Administrators, house officers, nurses, pharmacists, respiratory
therapists, medical and nursing students
 better understand the dynamics of multidisciplinary rounds
 identify defects in communication
 foster collaboration among disciplines or practice domains
 target areas where communication can be improved in the
rounding process and in setting patient daily goals
CUSP IS A CONTINUOUS
JOURNEY!
THANK YOU