CUSP for Safe Surgery:
The Surgical Unit-Based Safety Program
Project Overview
Armstrong Institute for Patient Safety and Quality
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
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
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
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7. Ending Health Care-Associated Infections, AHRQ, 2009.
Armstrong Institute for Patient Safety and Quality
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/
Surgical Care Improvement Project (SCIP)
CMS National Impact Assessment of Medicare Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/QualityMeasures/Downloads/NationalImpactAssessmentofQualityMeasuresFINAL.PDF. March 2012; 42.
SUSP Project Overview
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
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
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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
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Armstrong Institute for Patient Safety and Quality
Project Goals
• To achieve significant reductions in surgical
site infection and surgical complication rates
• To achieve significant improvements in
safety culture
How will we get there?
Translating Evidence
Into Practice
(TRiP)
1. Summarize the
evidence
Reducing Surgical Site
Infections
Comprehensive Unit
based Safety Program
(CUSP)
•
Emerging Evidence
1.
Educate staff on
science of safety
2. Identify local barriers
to implementation
•
Local Opportunities
to Improve
2.
Identify defects
3. Measure
performance
•
Collaborative
learning
3.
Assign executive
to adopt unit
4.
Learn from one
defect per quarter
5.
Implement
teamwork tools
4. Ensure all patients
get the evidence
• Engage
• Educate
• Execute
• Evaluate
Technical Work
Adaptive Work
http://www.hopkinsmedicine.org/armstrong_institute
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
1.
2.
3.
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
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
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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 staff to identify and fix local
opportunities to improve
• Framing as social problem that can be solved
– Clinical communities
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.
How is SUSP different?
• Informed by science
• Led by clinicians and supported by
management
• Guided by measures
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Armstrong Institute for Patient Safety and Quality
SUSP Interventions
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
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
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Armstrong Institute for Patient Safety and Quality
Comprehensive Unit-based
Safety Program (CUSP)
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
Jt Comm J Qual Patient Saf 2010;36:252-60
Resources: http://www.ahrq.gov/cusptoolkit/
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
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Armstrong Institute for Patient Safety and Quality
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
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Armstrong Institute for Patient Safety and Quality
https://armstrongresearch.hopkinsmedicine.org/susp.aspx
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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
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Armstrong Institute for Patient Safety and Quality
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
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team to import if you desire
Armstrong Institute for Patient Safety and Quality
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.
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Armstrong Institute for Patient Safety and Quality
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
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Armstrong Institute for Patient Safety and Quality
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)
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Armstrong Institute for Patient Safety and Quality
Challenges
• Engaging frontline staff
– Staff time (2-4 hr/week for each RN, surgeon,
anesthesia, team leader, infection preventionist)
•
•
•
•
CUSP executive partnership
Data collection burden
Often no forum for joint learning
Need to learn together
– Many examples of success
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Armstrong Institute for Patient Safety and Quality
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 Coll Surg 2012;215(2):193-200.
Armstrong Institute for Patient Safety and Quality
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JHU Colorectal CUSP
*p<0.05
J Am Coll Surg 2012;215(2):193-200.
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Armstrong Institute for Patient Safety and Quality
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.
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Armstrong Institute for Patient Safety and Quality