CARDIOVASCULAR SURGICAL TRANSLATIONAL STUDY (CSTS)
ICU Monthly Team Checkup Tool
Hospital__________________________________________________
Unit__________________________________________________
Month_________________________________ Year_____________________________________
Data Not Collected for this period.
SCIENCE OF SAFETY TRAINING
1. Since you began participating in the project, what portion of your staff have viewed a
science of safety video or presentation?
Please Circle: your own
the Peter Pronovost version
None/few □
Under ½ □
½□
Over ½ □
Almost All/All □
2. Is the Science of Safety video or presentation now part of new staff orientation for your
unit? (This new staff orientation should include all providers such as physicians, nurses,
and respiratory therapists.)
Yes □
No □
STAFF SAFETY ASSESSMENT
3. Did you survey staff about how the next patient might be harmed (two question survey)?
(It is important to note that the Staff Safety Assessment should be administered at the
start of the project and as needed thereafter.)
Yes □
No □
No, but we used a different method to assess how the next
patient might be harmed □
3a. If you checked Yes for having administered the Staff Safety Assessment, were
safety issues grouped and prioritized?
Yes □
No □
Please answer the following questions with respect to the last month only:
IMPLEMENTATION OF CUSP TOOLS
4) Please indicate the CUSP activities in which your team participated last month by checking
all that apply.
No
a) Morning Briefing
b) Daily Goals
c) Observing Rounds (i.e., A fly on the wall)
d) Culture Checkup Tool
e) Shadowing Tool
f) Barrier Identification and Mitigation Tool
g) Learning from Defects
h) Structured Communication tools, e.g.,
SBAR, DESC, ALEEN
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Planning Pilot
Implemented
stage
testing
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5. Last month, how many times did your CUSP team meet?
(Please enter #.)
IMPLEMENTATION OF CLABSI REDUCTION STEPS
6. What portion of the time do staff on the unit consistently use the following?
Never/Rarely Under ½ ½ the Over ½
the time
time the time
a) Appropriate hand hygiene
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b) Use of chlorhexidine in a back
and forth motion for skin
preparation
c) Full-barrier precautions during
the insertion (maintaining a
sterile field)
d) Avoiding the femoral site for
placement
e) Removing unnecessary lines
f) Monitoring of line insertion by a
second provider who is not
placing the line
g) Violation of line insertion
protocol
h) Halting line insertion if protocol
is violated
i) Use of a line maintenance
protocol
Almost
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8. If there was an infection in the last month, was a full investigation of causes conducted?
Yes □
No □
IMPLEMENTATION OF SSI REDUCTION STEPS
(section to be added later)
IMPLEMENTATION OF VAP REDUCTION STEPS
(section to be added later)
SENIOR EXECUTIVE PARTNERSHIP
9. Last month, how often did your senior executive meet with your CUSP team regarding this
ICU CUSP project? (Please enter #.)
10. Please indicate the type of data shared with your senior executive partner last
month by checking all that apply:
Yes No
a. ICU SSI infection rates
b. ICU CLABSI infection rates
c. ICU VAP infection rates
d. Findings from the Staff Safety Assessment
e. Data from the Hospital Survey of Patient Safety for ICU staff
f. Other quality improvement/patient safety initiatives
g. Learning from defects stories
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11. Last month, how often did your senior executive review your unit’s ICU performance
data (please enter #)?
DATA REVIEW AND SHARING
14. Last month, did your CUSP team have a chance to present your unit's performance data
(on CLABSI, SSI, VAP, barriers faced or audit/process data) to either of the following
entities? (Check all that apply.)
Yes No
a. Senior hospital/health system leadership
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b. Senior hospital/health system board of directors?
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15. How often did your CUSP team review ICU performance data last month? (Please enter
#.)
16. How often did your CUSP team share your performance results broadly with ICU staff last
month? (Please enter #.)
Nursing
Physicians___
17. In the last month, did the team identify a patient safety defect?
Yes □
No □
17a. If yes, did the team work through a process to learn from the defect?
Yes □
No □
17b. If yes, did the team share findings with others?
17b1. Yes, it was shared within the unit □ No □
17b2. Yes, it was shared outside the unit □ No □
BARRIERS TO PROGRESS
18. Last month, did any of the following slow your CUSP team's progress? (Check all that
apply.)
Never/Rarely
Under ½
the time
½ the
time
Over ½
the time
Almost
All/All
a) Insufficient knowledge of
evidence supporting
interventions
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b) Lack of team member
consensus regarding goals
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c) Not enough time
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d) Lack of quality improvement
skills
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e) Not enough buy-in from
physician staff members in
your area
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f) Not enough buy-in from
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nursing staff in your area
g) Not enough buy-in from
other staff in your area
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h) Staff Turnover on unit
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i)Turnover on CUSP team
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j) Confusion about how to
proceed with CUSP activities
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k) Burden of data collection
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l) Not enough leadership
support from executives
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m) Not enough leadership
support from physicians
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n) Not enough leadership
support from nurses
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o) Insufficient
autonomy/authority
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p) Competing priorities or
distractions (e.g., new EMR,
accreditation visit,)
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q) Inability of team members to
work together
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