CUSP for Safe Surgery (SUSP)
Project Management Guide
Armstrong Institute for Patient Safety and Quality
Problem Statement: Today’s healthcare environment is full of competing priorities, and it’s
easy for a new project to run out of steam. By anticipating project work and delegating
resources appropriately, your perioperative CUSP for Safe Surgery (SUSP) team can meet
project goals and sustain positive change.
Purpose of Guide: The purpose of this guide is to help your SUSP team successfully manage
the SUSP project in your perioperative area. This guide outlines the four project phases your
team will complete during the two-year project: Onboarding, Implementation I,
Implementation II, and Sustainment. This manual describes your responsibilities and activities
during each of the four project phases.
What is in this Guide? The guide consists of learning goals, materials, and deliverables for
each month of the project. It refers to forms and tools that you can find on the project web site,
https://armstrongresearch.hopkinsmedicine.org/susp.aspx. There is a short “SUSP Readiness
Bridge” checklist at the end of each section so you can track completion of project tasks.
Additionally, a project timeline lists project calls and phases to facilitate longer term project
planning.
Who Should Use this Guide? SUSP is a transdisciplinary project that incorporates the
wisdom and unique perspectives of all providers and staff. However, in order to ensure timely
completion of project activities, your team will choose a team leader. This leader will oversee
SUSP implementation, and additional team members can help implement each of the steps.
While the entire SUSP team can use this guide, the team leader should refer to it as he or she
sets the project course.
How to Use this Guide: Your team leader can review this information with the group during
your first SUSP meeting, after you have listened to the SUSP Kickoff Webinar. Refer back to the
guide as you become more familiar with project goals and learning materials to determine if
your team is on track.
If you’re having trouble meeting project goals or completing action items, you
can discuss your challenges on project coaching calls, or start a discussion on the
SUSP Social Network.
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Onboarding Phase: Months One through Six
You can redesign your care system through technical and adaptive work to improve patient
safety and eliminate preventable harm. Technical work changes procedural aspects of care that
can be explicitly defined, such as skin prep procedures. Adaptive work changes the attitudes,
values, beliefs and behaviors of the people who deliver care.
Far too often, frontline staff feel like patient safety improvement efforts are done to them
instead of done with them. During the Onboarding Phase, your team will develop an SSI
prevention ‘bundle’ by tapping the wisdom of your frontline staff. When you give voice to
the patient safety concerns of the people who deliver care, you embed adaptive work in
your technical work – a proven approach to reducing preventable harm.
Learning Goals for the Onboarding Phase
 Distinguish between adaptive and technical improvement work.
 Measure your perioperative safety culture and surgical site infection (SSI) rates, and
debrief that data with your frontline staff and senior executive.
 Develop a tailored SSI prevention bundle by tapping the wisdom of your frontline
staff and auditing your surgical care processes.
SUSP Kickoff Webinar
Length
2 hours
Dates
Monday, October 14 @ 10AM
Wednesday, October 16 @ 2PM
Webinar Info*
(all webinars are recorded)
Conference Line: 1-800-311-9401
Passcode: 83762
Webinar URL: https://connect.johnshopkins.edu/suspcohort4/
Target Audience
SUSP Teams and Coordinating Entities
Objectives
After this module, SUSP
Teams should be able to:




Tools
Deliverables
CUSP for Safe Surgery Team Membership Form
CUSP for Safe Surgery Team Roles and Responsibilities Form


Coming in two weeks
Identify the goals and conceptual model of the SUSP project
Describe SUSP project “asks” that will help ensure hospital team
success
Describe what the SUSP project will look like in your hospital
Prioritize your team’s next steps
Schedule your first SUSP meeting and complete the CUSP for Safe
Surgery Team Membership Form and CUSP for Safe Surgery Team
Roles and Responsibilities Form during that meeting
Report your pre-mortem insights during a coaching call
Knowledge is power. We’ll teach you how to generate safety culture and
SSI data reports from the SUSP portal.
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Training Call: How to Use the SUSP Portal: A Training Call for SUSP Facilitators
Length
1 hour
Dates
Monday, October 28 @ 10AM
Wednesday, October 30 @ 4PM
Webinar Info
Conference Line: 1-800-311-9401
Passcode: 83762
Webinar URL: https://connect.johnshopkins.edu/suspcohort4/
Target Audience
SUSP Facilitators: SUSP Team Lead and/or Data Lead, HSOPS Survey
Coordinators, & Coordinating Entities
Objectives



After this module, SUSP
Facilitators should be able
to:
Tools
Deliverables
SUSP Registration Fast
Facts


Coming in two weeks
Identify the roles and responsibilities of SUSP facilitators
Explain the SUSP portal registration process
Describe the HSOPS administration and SSI data transfer processes
SUSP SSI Data Fast
Facts
SUSP HSOPS Fast Facts
Complete the SSI Data Fast Facts checklist and download your
hospitals’ SSI report for the month of October
Complete the SUSP HSOPS Fast Facts checklist and bring a copy of your
HSOPS report to the January 13th call
Give your frontline staff the vision to see system-level defects, and the
voice to create a local SSI prevention bundle they can own.
Module 1: Train Everyone on the Science of Safety & Identifying Defects
Length
1 hour
Dates
Monday, November 11 @ 10AM
Wednesday, November 13 @ 4PM
Webinar Info
Conference Line: 1-800-311-9401
Passcode: 83762
Webinar URL: https://connect.johnshopkins.edu/suspcohort4/
Target Audience
SUSP Teams and Coordinating Entities
Objectives



After this module, SUSP
Teams should be able to:
Educate frontline staff and executive partner on the science of safety
Administer the PSSA and collate staff responses
Locate SUSP resources on the project website
Science of Safety Video
Tools
Science of Safety
Factsheet
Perioperative Staff Safety
Assessment (PSSA)
Deliverables
Report out top 3 PSSA responses on a coaching call
Coming next month
SUSP Team + Senior executive = Win-Win. We’ll tell you how to help your
exec roll up his or her sleeves and jump into SUSP work.
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Module 2: Engage Senior Executives in SSI Prevention Work
Length
1 hour
Dates
Monday, December 9 @ 10AM
Wednesday, December 11 @ 4PM
Webinar Info
Conference Line: 1-800-311-9401
Passcode: 83762
Webinar URL: https://connect.johnshopkins.edu/suspcohort4/
Target Audience
SUSP Teams and Coordinating Entities
Objectives

After this module, SUSP
Teams should be able to:


Tools
Identify three reasons why your SUSP work is important to your
executive and your organization as a whole
Identify three differences between executive participation in SCIP and
the role of the executive on the SUSP team
Develop and use successful strategies for engaging your executive in
SUSP work
Executive Safety Rounds Kickoff Template
Safety Issues Worksheet for Senior Executive Partnership
Deliverables


Coming next month
Data can’t become action until it’s been debriefed. Learn how next month!
Schedule your Executive Safety Rounds Kickoff Meeting
Identify your organization’s strategic goals and have a conversation
with your senior executive about how SUSP supports them
Module 3: Turning Data into Action: Using HSOPS and SSI data as part of meaningful change
Length
1 hour
Dates
Monday, January 13 @ 10AM
Wednesday, January 15 @ 4PM
Webinar Info
Conference Line: 1-800-311-9401
Passcode: 83762
Webinar URL: https://connect.johnshopkins.edu/suspcohort4/
Target Audience
SUSP Teams and Coordinating Entities
Objectives



After this module, SUSP
Teams should be able to:

Tools
Interpret SUSP safety culture and SSI data
Conduct a Culture Debriefing session with your frontline staff
Present your perioperative area’s SSI rates and HSOPS results during
Executive Safety Round Kickoff Meeting
Locate SUSP resources on the project website
Culture Debriefing Tool
Training Manual: Generate SSI Reports
Deliverables

Coming next month
You’re ready to create your local SSI prevention bundle. We’ll tell you how!
Complete the Culture Debriefing Tool with your frontline staff
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STOP:
SUSP READINESS BRIDGE # 1
Check:
o
o
o
o
o
Are your frontline SUSP team members aware of the SUSP project?
Have you completed a safety culture survey (e.g. HSOPS) and debriefed your
frontline SUSP team members?
Has your staff received the Science of Safety Training?
Have you collated Perioperative Staff Safety Assessment responses from your
staff?
Have you held your Executive Safety Rounds Kickoff meeting?
Module 4: Build your SSI Prevention Bundle
Length
1 hour
Dates
Monday, February 10 @ 10AM
Wednesday, February 12 @ 4PM
Webinar Info
Conference Line: 1-800-311-9401
Passcode: 83762
Webinar URL: https://connect.johnshopkins.edu/suspcohort4/
Target Audience
SUSP Teams and Coordinating Entities
Objectives

After this module, SUSP
Teams should be able to:




Use surgical care audit tools to gather data on the defects your staff
identified in the PSSA
Create a performance goal for your team
Develop a feasible SSI Prevention Bundle that addresses up to three
surgical care processes your team can improve
Describe how to proceed with improvements that don’t have a strong
evidence base
Locate SUSP resources on the project website
Surgical Care Audit Tools
Surgical Care Fast Facts Sheets
Tools
Deliverables

Coming next month
Every SSI is a learning opportunity. Adapt a tool to help your team
eliminate preventable harm.
Develop and share the elements of your SSI Prevention Bundle during a
coaching call
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Module 5: Perform an SSI Investigation
Length
1 hour
Dates
Monday, March 10 @ 10AM
Wednesday, March 12 @ 4PM
Webinar Info
Conference Line: 1-800-311-9401
Passcode: 83762
Webinar URL: https://connect.johnshopkins.edu/suspcohort4/
Target Audience
SUSP Teams and Coordinating Entities
Objectives
After this module, SUSP
Teams should be able to:



Distinguish between process and outcome data
Describe how the SSI Investigation Tool can guide improvement work
even when SSI rates are low
Adapt an SSI Investigation Tool to reflect the care processes in your
SSI Prevention Bundle
SSI Investigation Tool
Tools
Deliverables
Coming next month

Complete an SSI investigation of your most recent SSIs
Believe it or not, bundle development was the easy part. We’ll help you
ensure that every patient receives your well-developed intervention.
STOP:
SUSP READINESS BRIDGE # 2
Check:
o
o
o
Have you used auditing tools to develop an SSI Prevention Bundle?
Have you created a tailored SSI Investigation Tool to help your team “learn
from defects”?
Have you reviewed your SSI data and made a plan to do so on a regular basis?
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