On the CUSP:
Lessons from the Michigan Keystone ICU Project
Going where no state had gone
before…
© 2009
Learning Objectives
• To become familiar with a successful large-scale
improvement project: Keystone ICU
• To understand some of the Lessons from that project
• To think about how those lessons might help in your
local quality and patient safety improvement
efforts
© 2009
Keystone ICU
• AHRQ:“Patient Safety Matching Grant” 2003-2005
– Johns Hopkins Quality & Safety Research Group and Michigan
Health & Hospital Association Keystone Center
• Over 100 intensive care units (77 hospitals)
– Implemented The Comprehensive Unit based Safety Program “
CUSP”
• Statistically significant improvement in safety and teamwork
climate
• Implemented evidence-based interventions to reduce
catheter related blood stream infections in ICUs
• Statistically significant reduction in CLABSI (66% reduction)
© 2009
Understand the differences
between leadership and authority:
• Senior leader involvement is important
– CUSP executive early builds the support system
• Leadership however, is a skill not linked to “position”
• Formal and informal leaders are both important
• Invite all interested individuals to be part of the
improvement team
Goal: Cultivate Leaders
© 2009
Recognize technical versus adaptive work
• Technical work is knowledge based and focuses on
CONTENT
– Defining the project, selecting measures, defining
variables and data collection methods, analyzing data
and preparing reports are all TECHNICAL activities and
most efficiently managed at a central level
• Adaptive work is behavior, or values based and
focuses on CONTEXT
– Implementing interventions, respecting wisdom of the frontline, developing a plan that addresses both “head and
heart” must be managed at a local level
Goal: Get the Technical and Adaptive Work Right
© 2009
Strive to find the sweet spot
• Interventions with the strongest evidence
– (lowest number needed to treat)
• Interventions with the fewest implementation barriers
• Minimize burden of data collection
– Sacrifice on quantity, not quality of data
Goal: Find a Balance
What is both Scientifically Sound and Feasible?
© 2009
Database Design is Critical
• Match project goals, objectives and database
design in the beginning
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Clearly defined goals and objectives
Written plan to measure progress toward goals
Estimate of baseline performance
System for measuring performance
• Critical to get reports back to frontline staff as well
as administrative leaders
• Transparency
Goal: Begin with the End in Mind
© 2009
Minimize the bias in data collection
• Rigor of QI studies is often limited
• Methods to minimize bias include:
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Create a manual of operations and data dictionary
CDC has standard definitions; we need to use them
Pilot test data collection forms
Create a data quality control plan
• Process to train data collectors & evaluate reliability
• Imbed range checks in the database
• Critical to minimize missing data
– Greatest risk to validity of effort is poor data
Goal: Strive to minimize bias; be transparent where it exists
© 2009
Reduce the quantity not the
quality of data
• Be realistic about the burden of data collection
• Appreciate the challenges of measure selection
– Face validity
– Physician engagement
• Acknowledge the importance of complete data
– Biased data is worse than no data
Goal: Commit to data that is meaningful, feasible and
answers the question: Is Care Safer?
© 2009
Link culture and clinical outcomes
• Creating a culture of safety and teamwork may
enhance ability to implement clinical interventions
• May be a relationship between unit climate and
sustainability of improvement
• The Comprehensive Unit-based Safety Program
(CUSP) provides structured tools to help achieve
culture improvement (adaptive change)
Goal: Learn from linking culture and clinical data
© 2009
Stay focused on original aims
• Scope creep can kill a project
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Enthusiasm to improve care
Frustration with challenges of project implementation
Deplete resources
Diffuse energy
• No new interventions until achieve goal of “current”
intervention
Goal: clear, consistent focus on original aims
© 2009
Keep a laser sharp focus on patients
• Hospital, clinician and unit “perspectives” are
unique
– Conflicts WILL arise
• Commitment: harm is untenable
– Communication tools help bridge the gap
– Address gaps between spoken support and actions
• Patients are the north star
Goal: What is best for patients guides the work
© 2009
Expect the project to stall at intervals
• Every project stalls
– Important to listen for the “music beneath the words”
• Listen deeply
– Respond honestly
• Most people don’t fear change; they fear loss
– Surface issues; address fears; then move forward
• Change happens “at the edges”
– Understand that timeline may need to flex in order to meet
project goals
Goal: Look at “Pauses” as an opportunity for deep learning
© 2009
Innovate to improve
• Need methodologic rigor and strict data management in
QI/Patient Safety studies
• All teams are capable of both in a partnership model (central
technical work/local adaptive work)
• Data collection that is narrow but deep provides important
knowledge for the industry
• Studies that are poorly designed and implemented waste
resources and mislead caregivers and the public
Goal: Support QI activities that are efficient, effective,
scientifically sound
© 2009
Action Items
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Commit: Harm is not tenable
Create a team
Assign responsibilities
Ensure you have a system for data collection
Create a system to regularly share project data
Participate on project calls
Implement interventions
Share experiences with other project teams
© 2009
References
•
Goeschel CA, Pronovost PJ, Harnessing the Potential of Improvement Collaboratives:
Lessons from the Keystone ICU Project. Advances in Patient Safety: New Directions and
Alternative Approaches. AHRQ 2008
•
Pronovost P J, Berenholtz S, Goeschel CA, Improving the Quality of Measurement and
Evaluation in Quality Improvement Efforts, American Journal of Medical Quality, Vol 23,
No 2. March/April 2008
•
Goeschel CA., Bourgault A, Palleschi M, Posa P, Harrison D, Tacia L, et al. Nursing Lessons
from the MHA Keystone ICU Project: Developing and Implementing an Innovative
Approach to Patient Safety. Critical Care Nursing Clinics of North America . Vol 18. No 4.
Dec. 2006. 481-492
•
Needham DM, Sinopoli DJ, Dinglas VD, Berenholtz SM, Korupolu R, Watson SR,Lumbomski
L, Goeschel C, Pronovost PJ. Improving data quality control in quality improvement
projects. International Journal for Quality in Health Care. 2009. In press.
© 2009