On the CUSP: Stop BSI
The Comprehensive Unit-based Safety Program (CUSP)
© 2010
The Vision of CUSP
The Comprehensive Unit-based Safety Program is a
safety culture program designed to:
– educate and improve awareness about patient safety and
quality of care
– empower staff to take charge and improve safety in their
work place
– partner units with a hospital executive to improve
organizational culture and provide resources for unit
improvement efforts
– provide tools to investigate and learn from defects
© 2010
CUSP: 5 Steps
1.
Educate staff on science of safety
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from one defect per quarter
5.
Implement teamwork tools
Pronovost J, Patient Safety, 2005
CUSP Toolkit, http://www.safercare.net/OTCSBSI/Resources.html
© 2010
Working the Steps in CUSP
One Cycle of CUSP
From Start to Finish:
A Telemetry Unit
© 2010
Step 1: Educate
• All staff were educated on the Science of Safety
– Included nurses, technicians, clerical associates, and
housekeeping.
• All physicians are educated upon hire
• All nurses are educated upon hire.
© 2010
Step 2: Identify Defects
All staff were asked to complete the Staff Safety Assessment (Appendix C)
© 2010
Step 3: Executive Adopts a Unit
• The VP of Security and Parking is the executive for
this unit.
• The Executive along with the CUSP team reviewed
the Staff Safety Assessment to identify select a
defect to work on and learn from.
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Staff Safety Assessment Results
N=24*
*2 answered unit is safe
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Staff Safety Assessment Results
• Staff had many ideas about how to reduce the falls
on this unit.
23 interventions involving:
• Bed
• Side rails
• Patient
• Environment
• Education
• Process changes
• Communication
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Step 4: Learning from Defects
The next CUSP meeting the team started the Learning
from Defects tool (Appendix G).
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Step 4: Learning from Defects
• To answer section I the team needed to understand
if there were any common themes/risk factors
related to the falls on this unit.
• Reviewed 12 months of fall data:
– 90% of falls occurred on night shift, within 1 hour of change of
shift, and on weekends
– Nurses reported they had forgotten to turn bed alarm back on
after giving care.
– Less nurses/staff around seemed to predict increased risk for fall or
day shift could compensate for bed alarms off when they had
more staff around
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Step 4: Learning from Defects
n/a
n/a
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Step 4: Learning from Defects
Team factor- adequate communication during care w/ ancillary staff
5
5
Caregiver factor- distractions lead to patients bed alarm not turned on
5
5
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Step 4: Learning from Defects
Independent double check for bed alarms
Add column to report sheet for patients with high fall risk
Every 4 hours staff will check Hill-Rom system to ensure bed alarms are on
© 2010
5
5
5
4
Step 4: Learning from Defects
Add column to report sheet to communicate high fall risk to ancillary staff
Rosemary
Develop checklist to allow staff to document that bed alarm on every 4 hours*
Stacey
*Timed with shift change- 02:00, 06:45, 14:45, 18:45, 22:45
- Clerical associate responsible for checking at all times except 02:00
- Charge RN responsible for 02:00 check
© 2010
9/15/09
9/15/09
Step 4: Learning from Defects
© 2010
Engage & Educate
Started engaging and educating staff as soon as falls identified as defect to
work on for CUSP project.
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NDNQI 10th Percentile
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NDNQI Median
Fall Rate (Falls per 1000 patient days)
Apr-10
Mar-10
Execute:
Independent
Double Check on
Bed Alarms
Engage
&
Educate
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
6
Sep-09
7
Aug-09
8
Jul-09
9
Jun-09
May-09
Apr-09
Mar-09
Feb-09
Jan-09
Dec-08
Nov-08
Oct-08
Sep-08
Aug-08
Jul-08
Jun-08
May-08
Apr-08
Mar-08
Feb-08
Jan-08
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Falls per 1,000 Patient Days
Step 4: Learning from Defects
Fall Rate
10
Evaluate
5
4
3
2
1
0
Step 4: Learning from Defects
Evaluate:
• 7 months prior to intervention
Mean - 2.85 falls per 1,000 patient days
• 7 months since the intervention
Mean - 1.33 falls per 1,000 patient days
• 50% reduction in falls
• Extremely low burden intervention
© 2010
Examples of CUSP in Action!!!
© 2010
Identified concern from Staff
Safety Assessment
(CUSP Step 2)
Recommended Improvements
(CUSP Step 4 & 5)
Interventions Implemented
Risk of central line associated bloodstream
infections
Make sure best practices are used for all central
lines insertions.
A line cart and checklist is used for all central
lines insertions.
Risk of central line associated bloodstream
infections due to poor compliance with IV tubing
changes
Make sure every central line IV tubing is changed
according to best practice.
New IV tubing labeling system used.
Risk of medication errors
Point of care pharmacist available on units
Pharmacist assigned
Poor management of pain
Create guideline or protocol for pain assessment
and management
Pain card at every bedside
Poor communication among ICU providers
Create Short Term Goals Sheet
Short term goals sheet used during rounds
Poor communication during ICU discharge
leading to medication errors in transfer orders
Implement medication reconciliation process at ICU
discharge
Medication reconciliation done at discharge
CUSP is a Continuous Journey
• CUSP is a marathon not a sprint
• Ask staff at least every six months how the next patient
is going to be harmed and invest the time and
resources to reduce this harm
• Learn from one defect per quarter and share lessons
learned
• Implement teamwork tools that best meet
the teams needs
© 2010