St. Joseph Mercy Health System
Keystone ICU Collaborative:
Making your ICUs safer
The secret ingredients are culture and team
Pat Posa RN, BSN, MSA
System Performance Improvement Leader
St. Joseph Mercy Health System
Ann Arbor, MI
patposa@gmail.com
Statewide 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 7 years!!!!







Science of
Safety(CUSP)
BSI
VAP
Daily Goals
Sepsis
Oral Care
Delirium and
Progressive
mobility
Partnership between Johns Hopkins University and MHA
Initiated with AHRQ Matching Grant Sustained with participant fees in
2005 and 2006
St. Joseph Mercy Hospital Story
CUSP in the ICU and beyond
Building on CUSP and CLABSI/CAUTI
for other work
Technical (evidence based
practices)
Adaptive (communication
and teamwork)
HAI infection prevention
MDR with daily goals
Sepsis identification and
management
Morning briefings/preprocedure briefings
Intra-abdominal HTN
Learn from defects
Delirium
Huddles
Progressive mobility
Crucial Conversations training
Just Culture training
Start with:
Keystone ICU Team
Denise Harrison RN, MSN, Director
of Critical Care
Christine Curran, MD, medical
director, MICU
Mary-Anne Purtill MD, medical
director SICU
Pat Posa RN, MSA, system
performance improvement leader
Marco Hoesel MD, surgical resident
Amy Heeg RN, BSN CCULivingston
Brian Kurylo RN, CCU
Cathy Stewart RN, BSN, CCRN
Resourse Pool
Toy Bartley, RN, Clinical nurse
leader, MICU
Diane Jones PA, cardiac surgery
David Holmes, cardiac surgery
Sondra RN CCU-Livingston
Andreea Sandu RN, MICU
Nancy Payne RN, MICU
Laura Buwalde, RN, SICU
Emily McGee, RN, Clinical Nurse
Leader, SICU
Shikha Kapila, Pharm. D
Cheryl Morrin MPH, infection control
Chris Kiser, Pharmacy, Livingston
Beverly Bay-Jones, RRT, Resp
Therapy
Tahnee Thibodeau., RD, MICU
dietitican
Wendy Nieman RN, Project Impact
The “Secret Ingredient”
Comprehensive Unit-Based Patient
Safety Program
Pre-CUSP work


1.
2.
3.
4.
5.
Form a unit CUSP team
Measure unit culture
Educate staff on Science of Safety
Identify defects using the Staff Safety
Assessment; prioritize defects
Executive adopts the unit
Learn from one defect per quarter
Implement team/communication tools
Keep focus on this throughout the journey!!!
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
Measure culture at the unit level
Pronovost, PJ et al. Clin Chest Med, 2009;30:169-179
Unit CUSP team/Culture
measurement and action plan
Unit teams meeting at least monthly?
What are your challenges?
 What strategies have been successful?

Developed action plan from culture
survey result?

What are some of interventions you have
implemented?
Understand system determines performance
Use strategies to improve system performance
 Standardize
 Create Independent checks for key process
 Learn from Mistakes
Apply strategies to both technical work and team work.
Recognize that teams make wise decisions with diverse
and independent input
How we do this:
• Educate all personnel in all the ICU—RN, RT, residents, PA/NP
• Educate the attending---difficult but important
• Part of orientation
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
Why do mistakes happen
“Every system is perfectly
designed to achieve the results it
gets”
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
Communication is Key
Effective communication amongst caregivers is
essential for a functioning team
The Joint Commission reports that ineffective
communication is the most commonly cited cause for
a sentinel event
Observations of ICU teams have shown errors in the
ICU to be concentrated after communication events
(shift change, handoffs, ect)
30% of errors are associated with communication
between nurses and physicians
Reader, CCM 2009 Vol 37 No 5;
Donchin CCM 1995 Vol 23
Effective Teamwork and
Communication Requires:
Structured Communication
Assertion/Critical Language
Psychological Safety
Effective Leadership
SBAR, structured handoffs
Key words, the ability to
speak up and stop the
show
An environment of respect
Flat hierarchy, sharing the
plan, continuously inviting
other team members into the
conversation, explicitly asking
people to share questions or
concerns, using people’s
names
Safety Issues Survey
1.
2.
3.
Tell us about the last patient who would have been
harmed without your intervention.
How will the next patient be harmed?
What steps can you do to prevent this harm?

by either preventing the mistake, making the mistake visible or
mitigating the harm should it occur
This is a very important tool. Use this to identify some of the
‘whys’ mistakes are happening and what is impacting culture
Taking an identified patient safety issue from the frontline staff and
create an action plan to resolve this is an early win for this program
and staff buy-in
Science of Safety Education/Staff
Safety Assessment
Challenging to educate attending
physicians

What strategies have you used?
Staff safety assessment is very important
tool
How many have done this- once? > 1 times?
 Have you utilized the LFD tool to help resolve
issues identified?

Executive Safety Partnerships
Page 17
Best Practices: Humble Curiosity
• Help your staff to feel heard – unheard staff
find an ear elsewhere, at your expense
• Remember your role as a leader isn’t always
to solve problems, it is, at times to listen to
staff and learn from them while you
empathize
• Show curiosity in staff feedback –
– Don’t be defensive: defensive leaders have
defensive followers
if you are defensive: “Why was that so low…,”
they will be defensive and not engage
instead engage “Teach me, what can be done to
remove barriers so that your concerns are
addressed?”
18
Learn from a Defect Tool
Designed to rigorously analyze the various
components and conditions that contributed
to an adverse event and is likely to be
successful in the elimination of future
occurrences.
Tool can serve to organize factors that may
have contributed to the defect and provides a
logical approach to breaking down faulty
system issues.
Learning from Defects Tool
Page 20
Finding Defects to Learn From
Staff feedback/issues identified on unit
Event reporting
Quality and safety measures
Gaps in application of the evidence
Have staff complete short 3 question
survey
Mistakes and near misses are
defects
Have each ICU present learning from a
defect each quarter----now doing monthly
NG placed in the lungs
 Missed respiratory treatments
 Delay in radiology tests for ICU pts
 Non-compliance with contact precautions

This is very hard to continue to do, we did it first for the first year.
We didn’t keep it up----but are now doing this almost daily through
our huddles, The biggest challenge is following up on each action
plan giving the feedback to the staff.
Learn from Defect
How many are doing this on the unit—
quarterly? Monthly?
How are you sharing the learnings with
the unit staff and beyond?
Daily rounds/goals
Pre-procedure briefing
Morning briefing
Huddles
Learn from a defect
Executive Safety Rounds
Standardize handoffs
Simulation
Crucial Conversations
Interdisciplinary rounds with daily
goals
Purpose: Improve communication among care team
and family members regarding the patient’s plan of
care
Goals should be specific and measurable
Documented where all care team members have
access
Checklist used during rounds prompts caregivers to
focus on what needs to be accomplished that day to
safely move the patient closer to transfer out of the
ICU or discharge home
Measure effectiveness of rounds—team dynamics,
communication
MDR with DG Action Plan
Task
Obtain executive buy-in
Define members of rounds and their
roles
Define time of day and frequency
Structure of rounds:
•Review of systems (or major issues)
•Define components of checklist
•Time for each patient
Documentation:
•What is documented in medical record
• daily goal—where is it documented?
Educating staff
Define metrics and evaluation process
26
Responsibility Due Date
Interdisciplinary rounds with daily goals--Challenges and Opportunities
Hardest initiative to implement, especially if you have an open
unit and/or no intensivists and on floors without dedicated
physician team assigned to unit
We had each unit create their own daily goal checklists---each
unit culture and process is different. Changed this form multiple
times---and in two units we gave up.
Focused first on create a daily goal and recording those either
on the white board in the room or on a sheet of paper
Two years ago: closed our MICU and started intensivist program
in the SICU
Relooked at this again, and focused on team dynamics and
created a defined role for the nurse: survey and
observation
Nursing
Card
VAP
Delirium
Sepsis
28
MDR with Daily Goals
Anyone done this successfully in an
open ICU or in a non-ICU unit (without
dedicated physician staff)?

What strategies did you use that lead to
your success?
Pre-procedure briefing
•
•
•
•
•
Make introductions
Discuss patient information and procedure
Agree upon a time for line insertion
Review best practice for line insertion (if necessary)
Nurse defines their role to physician: provide equipment, monitor
patient, provide patient comfort, observe for compliance with best
practices and STOP procedure if sterile process compromised
• Establish communication expectation for sterile procedure breaks
• Examples include: your sleeve has touched the IV pole, the guidewire touched the headboard
• Identify any special supply or procedural needs
• Discuss any special patient issues (IE: patient confused, patient awake)
• Answer any additional questions
TIME OUT: RIGHT PATIENT---RIGHT PROCEDURE
Used this when rolled out CLABSI bundle to non-ICU
Morning Briefing
Purpose: Increase communication between physicians
and nursing staff while efficiently prioritizing patient care
delivery and ICU admissions and discharges
What is it?
 A morning briefing is a dialogue between 2 or more
persons using concise and relevant information to
promote effective communication prior to rounds
Have used this for a long time between charge nurses from
shift to shift. Since we have closed the units, now this also
occurs with charge nurse and intensivist.
Morning Briefing
Tool: answer following questions
What happened overnight that I need to
know about?
 Where should I begin rounds? (patient that
requires immediate attention based on
acuity)
 Which patients do you believe will be
transferring out of the unit today?
 Who has discharge orders written?
 How many admissions are planned today?
 What time is the first admission?

Huddles
Enable teams to have frequent but short briefings so that
they can stay informed, review work, make plans, and
move ahead rapidly.
Allow fuller participation of front-line staff and bedside
caregivers, who often find it impossible to get away for
the conventional hour-long improvement team meetings.
They keep momentum going, as teams are able to meet
more frequently.
Improve staff’s situational awareness
Beginning to use this strategy to begin
to recovery immediately from defects--IE: falls, sepsis
Components
Components
Metric 1: Quality/Safety
Metric 2: Patient Satisfaction
Metric 3: Operations
Daily Critical Communications
Information
Ideas in Motion
How to do it?
•Beginning or mid shift
•5-10 minutes
•Lead by member of unit
leadership team
34
Structured Huddles Action Plan
Task
Obtain executive buy-in
Order Huddle board
Select Huddle metrics for first board: operational,
quality/safety and patient satisfaction
Define huddle process:
•Define time of day and frequency
•Who will lead huddle
•Expectations of staff—who will attend
•Create agenda (in first huddles include overview
of purpose of huddles and huddle process)
Hang huddle board and fill in metrics
Identify when huddles will begin
Define process for changing huddle metrics
Create evaluation process: how will I know if
huddles are successful?
35
Responsibility Due
Date
SICU Huddle Board
36
Surgical Unit Huddle Board
Medical Unit Huddle Board
Safety Climate-Michigan ICUs
Sexton, CCM 2011
39
% of respondents within an ICU reporting good teamwork climate
100
90
80
Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence:
caregivers feel comfortable speaking up if they
perceive a problem with patient care
70
60
50
40
30
20
10
No BSI = 5 months or more w/ zero
No BSI 21%
No BSI 31%
No BSI 44%
0
Health Services Research, 2006;41(4 Part
40
II):1599.
100
Teamwork Climate &
Annual Nurse Turnover
% reporting positive teamwork climate
90
80
70
60
50
40
30
20
High Turnover
10 16.0%
Mid Turnover
10.8%
Low Turnover
7.9%
0
RN Teamwork Climate
Staff Physician Teamwork Climate
41
“Needs Improvement” Statewide
Michigan CUSP ICU Results
•
“Needs Improvement” means
less than 60% of respondents
reported good safety climate
• Statewide in 2004 84%
needed improvement, in
2007 23%
• Safety Climate item that
drives improvement: “I am
encouraged by my
colleagues to report any
patient safety concerns I
may have”
42
ICU Teamwork Climate 2004-2008
ICU Safety Climate 2004 - 2008
Impact of a statewide intensive care unit quality
improvement initiative on hospital mortality and
length of stay
BMJ, February 2011
Method
Retrospective comparative analysis
Study period: October 2001 to December 2006
Study sample: all hospital admissions with an ICU stay
for adults age 65 or older at hospitals with 50 or more
acute care beds and 200 or more admissions to the ICU
during that time period
95 study hospitals in Michigan compared with 364
hospitals in surrounding Midwest region
Look at hospital mortality and length of hospital stay
Impact of a statewide intensive care unit quality
improvement initiative on hospital mortality and length of
stay; BMJ, February 2011
Results: Odds ratio for mortality in Michigan and
comparison hospitals
Study group
Comparison
group
P value
PreImplementation
0.98(0.94 to 1.01)
0.96 (0.95 to 0.98)
0.373
PostImplementation
1-12 months
0.83 (0.79 to 0.87)
0.88 (0.85 to 0.90)
0.041
PostImplementation
13-22 months
0.76 (0.72 to 0.81)
0.84 (0.81 to 0.86)
0.007
Why Crucial Conversations?
2005 study by AACN and Vital Smarts:
Silence Kills
1,700 nurses, physicians, clinical care staff and
administrators
 More than 50% witnessed their co-workers
breaking rules, making mistakes, failing to support
others, demonstrating incompetence, showing
poor teamwork, acting disrespectfully and
micromanaging
 Despite the risk to patients, less than 10% of
physicians, nurses, and other clinical staff directly
confronted their colleagues about their concerns
195,000 deaths per year in US hospitals because of medical mistakes

Why Crucial Conversations?
2010 Silent Treatment Study—AACN,
AORN and Vital Smarts






Healthcare has made great strides over past 5 years to
improve systems to prevent errors
Safety tools are an essential part of the formula for solving
avoidable medical errors caused by poor communication.
Silent Treatment study of 6,500 nurses and nurse managers
reveals that safety tools fail to address a second category of
communication breakdowns---undiscussables.
Tools don’t create safety—people do
In study—85% of respondents had been in a situation where
a safety tool warned them of a problem----BUT 58% had also
been in situations where they felt unsafe to speak up about
the problems or were not able to get others to listen
Staff need the tools to know how to effectively speak up!
Principles of Crucial
Conversations
Start with Heart

How to stay focused on what you really want.
Learn to Look

How to notice when safety is at risk.
Make it Safe
How to Make it Safe to Talk about Almost
Anything.
 How to create mutual purpose.

Principles of Crucial
Conversations
Master my Stories


How to stay in dialogue when you’re angry, scared, or hurt
How to Master Emotions and return to dialogue
STATE my Path

How to speak persuasively, not abrasively
Explore others Path


How to listen when others blow up or clam up
Seek First to Understand…Then to be Understood
Move to Action

How to turn crucial conversations into action and results
Teamwork/Communication
Tools
Anyone implemented any team tools?
Morning briefings?
 Pre-procedure briefings?
 Structured huddles?
 Crucial Conversations?

What are some of your successes/challenges?
CUSP-Challenges and Strategies
Issues
Strategies
Engaging frontline staff (including
off-shifts) owning this work
Part of team(especially night shift
staff), bulletin boards, newsletters,
huddles
Timely follow through with identified
defects or safety issues and
strategies to resolve
Manager shares updates/status at
staff meetings, communication at
huddles, created huddle book
Continued engagement of the
executive
MHA Keystone letters to executive,
locally at each hospital—through
one on one conversations
Implementing strategies and tools to Learn from a defect, MDR with
help improve culture and teamwork focus on communication, survey
team members on perception of
communication, morning briefings,
debriefings, huddles, crucial
conversations
Continual learning from defects
Have each unit learn from a defect
monthly and share at meetings
Lessons Learned
Spend sufficient time on CUSP before moving on to
implementing practice changes
CUSP is the foundation and needs to be a continued
focus-----forever!!!!
Must work on culture and team improvement
strategies throughout the journey
CUSP must be unit based. Culture is different on
each unit, therefore opportunities for improvement
and strategies might be different
Define at beginning a communication plan that
includes all levels of the organization
This work must be the responsibility of everyone,
but important to have someone who’s job is to
focus and drive this daily
Can we change practice through
process improvement alone?
or
Will successful change require
an altering of the value structure
within the unit?
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.”
Atul Gawande, Better: A Surgeon’s Notes on Performance
QUESTIONS ?????