CUSP for Ventilator
Associated Pneumonia
(VAP)
Table of Contents
Introduction ................................................................................................................................ 3
CUSP is Local ............................................................................................................................... 3
How Does CUSP Change Local Culture?.................................................................. 4
CUSP Steps: An Overview ........................................................................................................... 4
Who is Accountable for CUSP? ............................................................................... 5
Pre-CUSP Work ........................................................................................................................... 5
Assemble a CUSP Team........................................................................................... 5
Assess your Culture of Safety (Baseline Assessment) ............................................ 6
CUSP Steps .................................................................................................................................. 7
Step 1: Science of Safety Training ........................................................................... 7
Step 2: Staff Identify Defects .................................................................................. 8
Step 3: Senior Executive Partnership ................................................................... 10
Step 4: Learning from Defects through Collective Sensemaking ......................... 11
Step 5: Use Tools to Improve ............................................................................... 12
CUSP is an Ongoing Process, Not an Endpoint ......................................................................... 14
Getting Help .............................................................................................................................. 14
Appendices................................................................................................................................ 15
References ................................................................................................................................ 17
Introduction
Healthcare organizations around the world are increasingly focused on patient safety and healthcare quality.
While healthcare providers are committed to improvement efforts, many struggle to create and sustain
positive change. The Comprehensive Unit-based Safety Program (CUSP) helps providers achieve the lasting
improvements they seek.
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 the evidence to support a specific intervention or the definition for a VAP. Adaptive work changes the
attitudes, values, beliefs and behaviors of the people who deliver care and determine whether patients
receive the best available evidence-based care.
Adaptive work can be discouraging and nebulous. Creating a protocol for elevating the head of the bed is far
easier than managing staff’s attitudes and values, or engaging staff to use the protocol. You may be tempted
to focus on technical work, and leave complex adaptive problems unaddressed. Yet many change efforts fail
because adaptive work is neglected: An evidence-based protocol or checklist (technical work) will only impact
outcomes if staff understand, value, and prioritize use of the checklist (adaptive work).
The five steps of CUSP bring adaptive work into the change process and help your team improve your unit’s
safety culture. By integrating CUSP with technical interventions, your team can achieve real and sustainable
improvements in safety.
The CUSP Toolkit in practice
In 2004, more than 100 intensive care units in the State of Michigan implemented CUSP in
their celebrated work to eliminate central line-associated bloodstream infections and
ventilator-associated pneumonia. Since their success, thousands of units nationwide have
used CUSP to target a wide range of safety problems: patient falls, hospital-acquired
infections, medication administration errors, among others.1-8 Check out the list of references
to learn more.
CUSP is Local
CUSP is perhaps the only intervention that has improved teamwork and safety culture on a large scale. Largescale change is achieved when multiple teams implement CUSP locally. Patient safety culture improvement at
the local unit-level is crucial. Local norms have a powerful influence on the attitudes and behavior of care
providers. Unit culture influences the extent to which providers participate in quality improvement efforts,
adhere to evidence-based guidelines, or even speak up when they are concerned about the care of a patient.
How Does CUSP Change Local Culture?
Frontline providers cultivate wisdom by delivering care within their local systems. They encounter patient
safety hazards on every shift and develop tactics to safeguard their patients against them. CUSP helps your
team improve local safety culture by tapping frontline wisdom. It provides a mechanism to change systems
and eliminate safety hazards for all patients. Far too often, frontline staff members feel like patient safety
improvement efforts are done to them instead of done with them. When frontline providers own the
improvement process, local safety culture improves.
CUSP Steps: An Overview
Though CUSP is comprised of five steps, the program is a continuous process designed to incorporate an
evidence-based patient safety infrastructure into your unit. The steps are briefly described below:
Step 1: Science of Safety Training
Introduce your teams to the principles that promote and support patient safety and quality. Help them
develop lenses to focus on system factors that can negatively impact care and lead to preventable harm.
Step 2: Staff Identify Defects
Identify patient safety defects in your work area. Your team can identify defects from incident reports,
liability claims, or sentinel events. In this step, ask frontline staff how the next patient will be harmed
through a short written survey.
Step 3: Executive Partnership
In this step, you’ll partner with a senior hospital executive to develop a shared understanding of local
defects, build consensus and a plan for how to mitigate those defects, and develop shared accountability
for implementing and evaluating the plan.
Step 4: Learning from Defects through Collective Sensemaking
Your teams will use a practical and valid tool to learn from defects, answering four basic questions:
1.
2.
3.
4.
What happened?
Why did it happen?
What did you do to reduce risk?
How do you know that risks were reduced?
Step 5: Tools to Improve
Use tools to improve teamwork and communication in the your unit. Teamwork and communication tools
include Daily Goals, and tools from the national TeamSTEPPS program.
Who is Accountable for CUSP?
CUSP is a transdisciplinary process 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 need to choose a
team leader. This leader will oversee the implementation of CUSP, and additional team members can help
implement each of the steps.
Pre-CUSP Work
Assemble a CUSP Team
The CUSP team transcends discipline silos. Transdisciplinary teams collaborate throughout the entire problem
solving process, instead of developing solutions in isolation and then trying to align them. The CUSP team
includes your team leader, a physician champion, a nurse champion, and a respiratory therapist champion.
The CUSP team leader and transdisciplinary project champions must be able to dedicate time to this project.
While the exact amount of time required will vary, we suggest a minimum of 2-4 hours per week to this
program. Additionally, hospital epidemiology or infection control professionals are important CUSP team
members, since they will contribute important expert advice and help with data collection for the project.
Your CUSP team will be most effective if it includes frontline staff from across the intensive care unit.
The CUSP team leader (or designee) should work with hospital management to connect with a senior
executive, and secure his or her commitment to the CUSP program. When selecting a senior executive, ensure
he or she is available to contribute meaningfully to the team and is approachable. Whether he or she has
experience as a clinician or not, your senior executive partner should be comfortable having important
discussions about difficult and sensitive topics.
Tools you can use
How you’ll use them
CUSP for VAP Team Membership Form
(Appendix A)
List team member names and contact information in this form.
Post the list in a visible location for staff reference.
CUSP for VAP Team Roles and
Responsibilities Form (Appendix B)
Clarify mutual expectations for CUSP team members
Our quality improvement department has worked on ICU improvement efforts for years. At first, we didn’t understand
why our hospital CEO had signed us up for CUSP for VAP. We thought, “We are already doing this stuff.” After joining a
few project calls, we began to understand that CUSP would require a different type of quality team that included
frontline staff and administrators, and a fundamental restructuring of how our hospital did quality work.
– CUSP for VAP Physician Champion
How do you get physician buy-in and protected time?
Join the conversation at the CUSP for VAP social networking site.
https://armstrongresearch.hopkinsmedicine.org/vap.aspx
Assess your Culture of Safety (Baseline Assessment)
The ongoing measurement of safety culture using surveys or questionnaires is quickly becoming an industry
norm in healthcare. If your organization has not conducted a safety culture survey, such as the Hospital Survey
on Patient Safety (HSOPS), it should be done in your unit at the outset of this project.
Safety culture questionnaires elicit frontline providers’ attitudes and perceptions about patient safety topics.
Individual providers complete the questionnaire anonymously, and responses can be reported by job category
(for example, nurse, physician, or respiratory therapist, etc.), by unit, or by hospital. Your team can reassess
clinical area safety culture every year or so.
Before administering a safety culture survey, explain its purpose to frontline providers. Emphasize that you
want to tap into their wisdom, opinions, and perceptions of safety on their unit, and ensure that they will
receive feedback on the results. All clinical and nonclinical providers who work in your ICU should be included
in this culture assessment (for example, nurses, physicians, respiratory therapists, physical therapists,
occupational therapists, and unit clerks).
Tools you can use
How you’ll use them
HSOPS Manual 1: Planning and
preparing for your survey
Learn how to plan and administer your survey, and make use of the
important data you collect.
Quick Guide: HSOPS CoordinatorRoles and Responsibilities
Find the HSOPS Coordinator who’s right for your project team.
Quick Guide: Template Debriefing
Plan
Now that you’ve collected data, making it actionable is the important
next step. A good debriefing plan will help. This template provides
some important tips.
We measure safety culture across the hospital every year, but when CUSP for VAP started, we saw an opportunity to
really assess our ICU culture. Even though our staff is tired of taking surveys, we administered HSOPS through the online
project platform. This time, we shared survey results and their interpretation with our staff. We told them that we
needed their leadership to make things better. Our frontline started to realize that they were the center of our quality
team.
— ICU Nurse manager, CUSP for VAP Team Member
How do you optimize HSOPS response rates and use your culture data? Join the conversation
at the CUSP for VAP social networking site.
https://armstrongresearch.hopkinsmedicine.org/vap.aspx
CUSP Steps
Step 1: Science of Safety Training
A “system” is a set of parts interacting to achieve a common goal. All too often we assume that patient harm
occurs because of inexperience, lack of supervision, or bad luck, when in fact care is delivered in imperfect
systems. Clinical area teams must understand the system in which they work to enable change in their clinical
setting.
Rather than being the main instigators of an
accident, operators tend to be the inheritors of
system defects…their part is that of adding the
final garnish to a lethal brew that has been long
in the cooking.
James Reason, Human Error
What the CUSP team needs to do
Have your staff view the Science of Safety video featuring Dr. Peter Pronovost. The CUSP team leader should
ensure that all clinicians and staff members watch the Science of Safety presentation within the first month of
CUSP implementation. Your CUSP champions can facilitate training for their respective disciplines. Training
can be done in large groups, several smaller groups, or during individual sessions depending on what is
practical for your clinical area.
Tools you can use
The Science of Safety
Video
(Watch the video)
How you’ll use them
This video will help your teams to:



Science of Safety Training
Attendance Sheet
(Appendix C)
Identify system failures that can impact patient safety
Apply design approaches that can be used to improve patient safety and
quality.
Make CUSP steps an integral part of unit processes
This form will help you track training completion
When we introduced this project to our unit, clinicians were quick to blame each other for our VAP rates. The nurses
blamed the doctors; the doctors blamed the nurses and respiratory therapists. We had to teach our staff that infection
rates are the result of faulty systems, not bad clinicians. Our VAP rate is not going to budge if all we do is exchange
blame. After the Science of Safety training, you could see a few lights go on. It’s definitely a journey, though. Clinicians
take care so personally.
– CUSP for VAP Nurse Champion
How do you train your entire clinical area staff?
Join the conversation at the CUSP for VAP social networking site.
https://armstrongresearch.hopkinsmedicine.org/vap.aspx
Step 2: Staff Identify Defects
Frontline providers understand patient safety risks in their clinical areas and have great insight into potential
solutions to these problems. Your team needs to tap into frontline providers’ knowledge and use it to guide
your safety improvement efforts. The Staff Safety Assessment helps you access this wisdom by directly asking
providers:




How will the next patient be harmed in your unit?
What do you think can be done to prevent this harm?
How will the next patient develop a ventilator-associated pneumonia (VAP) on your unit?
What do you think can be done to prevent this VAP?
One of the strongest determinants of safety culture is whether local and hospital leadership respond to staff
patient safety concerns. Therefore, it is important to follow up on the defects identified by your staff.
What the CUSP team needs to do
The CUSP team leader (or designee) should hand out a Staff Safety Assessment (SSA) form to all clinical and
nonclinical providers in the unit.
Timing: We strongly recommend that you hand out the Staff Safety Assessment form at the end of the
Science of Safety training session.
Logistics: One person should be assigned the task of handing out and collecting the safety assessment
forms. To encourage staff to report safety concerns, it may work well to establish a collection box or
envelope in an accessible location where completed forms can be dropped off.
Collective Sensemaking: Group SSA responses by commonly identified defects (such as communication,
medication process, equipment failure, supplies, etc.) and summarize defects (i.e., what percent of total
responses were related to communication?).
What comes first? Prioritize identified defects using the following criteria:




Likelihood of the defect harming the patient
Severity of harm the defect causes
How commonly the defect occurs
Likelihood that the defect can be prevented in daily work
A tool you can use
Staff Safety Assessment
(Appendix D)
How you’ll use it
Gauge perceptions of risks in your unit and tap into team wisdom to
proactively identify improvement targets
Our compliance rates for oral care were great. However, when we reviewed our SSA data, we were surprised that so
many staff were concerned about compliance. Their comments pointed out that surveillance using the EMR doesn’t
work for this particular measure. Through the SSA we discovered that this part of care can be copied forward with
several other care activities, and this is often done. However, because this is part of a ‘chunk’ of care activities, the care
may not have been completed. As we had already changed to the tear off kits, staff were able to see that oftentimes
not all kits were used at the end of the day and they were concerned that some patients were not receiving the care
they should. This issue of carrying forward tasks had previously been brought up by staff and we didn’t act on it It
became clear that we should have been listening..
– Quality Improvement Officer, CUSP for VAP Team Member
How do you get honest feedback about patient harm?
Join the conversation at the CUSP for VAP social networking site.
https://armstrongresearch.hopkinsmedicine.org/vap.aspx
Step 3: Senior Executive Partnership
The senior executive and frontline staff partnership are crucial to the CUSP team’s success. These partners
hold each other accountable for reducing risk to patients. At the unit-level, the senior executive stimulates
discussions about safety, helps prioritize and solve safety concerns, and helps set goals for the clinical area. At
the hospital-level, the senior executive may lobby for policy change, promote access to resources, or resolve
inter-departmental issues. Additionally, the senior executive is a bridge to the hospital’s C-suite (CEO, CMO,
CFO, etc.), and helps to share local wisdom with hospital administration and management.
What the CUSP team needs to do
The CUSP team leader (or designee) should schedule hour-long monthly safety rounds with the senior
executive. He or she should also prepare the senior executive for meaningful participation in safety rounds. If
the senior executive does not have a clinical background, offer a tour of your unit. Schedule time with your
senior executive to discuss unit-specific information. Include in this information packet:
1. Safety culture survey results
2. The prioritized list of safety issues compiled from the Staff Safety Assessment
3. Pertinent information about the unit that the senior executive may not know (for example, staff
turnover rate, compliance with process and policy measures and VAP rate).
Executive Safety Rounds
Executive safety rounds may begin with a senior executive walk-through of the clinical area, led by a frontline
clinician. The focus of executive safety rounds, however, is collaboration between the senior executive, CUSP
team, and frontline providers to address safety issues. Your team can solicit collaboration with sit-down
discussions that are open to all staff. Review identified safety issues together. The senior executive can help
prioritize your unit’s safety concerns. You can use quantitative (for example, numerically rating risk of harm)
or informal (for example, discussion until group consensus) methods to prioritize the greatest risks. Informal
methods tend to be less burdensome and can accurately reflect unit level risks.
Tools you can use
Executive Safety Rounds Kickoff
Template (Appendix E)
How you’ll use them
That first meeting’s very important for engaging your senior executive.
You can use this template for suggested activities and talking points.
Executive Safety Rounds Kickoff
Template (Appendix E)
That first meeting’s very important for engaging your senior executive.
You can use this template for suggested activities and talking points.
Safety Issues Worksheet for
Senior Executive Partnership
(Appendix F) (or a tracking log of
your choice)
A worksheet you can use for listing and prioritizing risks you’ve
identified.
Our VAP rates have definitely not been zero. During our CUSP meeting, we discussed the possibility of changing over to
the sub glottic endotracheal tubes as our next step to reduce our rates. Our executive was concerned about the
additional cost per tube and how that would affect the bottom line. We shared the literature we were given by the
CUSP for VAP: EVAP group regarding the cost savings associated with their use. He was impressed and decided to
support us in this endeavor. Next step? Convince the rest of the physicians that the tubes are a good idea and that we
need them to help us prevent VAP in our ICU..
– CUSP for VAP Team Leader
How do you engage your senior executive?
Join the conversation at the CUSP for VAP social networking site.
https://armstrongresearch.hopkinsmedicine.org/vap.aspx
Step 4: Learning from Defects through Collective Sensemaking
Once defects are identified and prioritized, the CUSP team must learn from them and implement
improvement efforts. The Learning from Defects through Sensemaking (LFD) worksheet (Appendix G) helps
frontline providers investigate safety defects: It guides CUSP teams through a structured process to answer
four questions:
1.
2.
3.
4.
What happened?
Why did it happen?
What did you do to reduce risk?
How do you know that risks were reduced?
What the CUSP team needs to do
Take a defect identified in your clinical area: an incident report, sentinel event, liability claim, or defect
identified from the Staff Safety Assessment; and complete the LFD worksheet. You may want to start with ‘low
hanging fruit’ and progress to more difficult problems as you gain experience with the LFD process. After you
are comfortable using and explaining the LFD process, you should discuss your LFD projects during executive
safety rounds.
A tool you can use
How you’ll use it
Learning from Defects
through Collective
Sensemaking Worksheet
(Appendix G)
Use this tool to lead discussions that engage frontline staff in characterizing
defects, uncovering system-level causes, and developing plans for improving
patient safety and quality. We recommend learning from at least one defect a
quarter.
We purchased the subglottic endotracheal tubes and placed them in the ICU, rapid response team cart, the ED and the
OR. We worked with the appropriate departmental heads and presented at Grand Rounds to assure that providers
understood the change, the reasons for the change and to answer any questions. We thought we had covered all our
bases. However, patients kept arriving from both the ED and OR with standard tubes. It was time to come up with a
solution that worked. We invited representatives the directors from the departments of surgery and anesthesiology to
our next monthly CUSP meeting. We used the Learning From Defects through Sensemaking at that meeting to
determine the issue and to develop a solution. The surgeons and anesthesiologists felt that the tubes were too big and
regardless of that, the expense too high if the patient would be extubated within 24 hours of surgery as planned.
Through this process we decided to work with the stakeholders develop an algorithm to help determine which patients
are more likely to need longer term intubation. We have already gone through several iterations of the algorithm, but
everyone seems to feel that they have been heard and fewer patients are admitted to the unit with a normal ETT. It
wasn’t easy to develop the algorithm and it is still being honed to meet the needs of the different stakeholders, but we
are making strides in bringing this important intervention to our patients
-- CUSP for VAP Senior Executive
How do you develop and evaluate your intervention?
Join the conversation at the CUSP for VAP social networking site.
https://armstrongresearch.hopkinsmedicine.org/vap.aspx
Step 5: Use Tools to Improve
Throughout this document, we’ve identified tools you can use as you implement CUSP for VAP. In this section,
we’ve listed some additional practical tools to help your team improve communication and teamwork. You
can find them, and others, in the CUSP Toolkit on the CUSP for VAP project website. Each tool comes with
detailed instructions.
What the CUSP team needs to do
Review your safety culture scores and determine which areas need improvement (for example, poor
teamwork climate). Collaborate with frontline providers to select a tool that best addresses their concerns.
More tools you can use
How you’ll use them
Daily Goals
Improve team communication and role clarity while caring for a
patient in the ICU.
When to use? This tool should be used with every patient. Research
shows it can make a big difference when used in a meaningful way.
AM Briefing Tool
Improve team communication regarding clinical area workflow with
this tool.
When to use? When staff believe that ICU workflow and
communication are poorly-coordinated
Shadowing Another Professional
Identify and improve communication, collaboration & teamwork skills
between different disciplines
When to use? When ICU staff members believe that disciplines need
to walk a mile in each other’s shoes.
After a few project gains, we realized that we could tap frontline wisdom every morning by implementing the Daily
Goals sheets. Now, as each case is discussed during rounds, a plan is developed for that patient’s care for that day. The
goals can involve everything from ordering an MRI to decreasing pain meds, to performing an SAT. Goals are discussed
with all staff present and documented. The documentation allows staff not present during rounds to help their patients
progress. We have found that Daily Goals are very effective for the night shift. They essentially have a status check for
the morning and directions on how to proceed for the night. We are not just ‘implementing CUSP’; we are building a
patient safety infrastructure.
-- CUSP for VAP Physician Champion
How do you optimize Daily Goals?
Join the conversation at the CUSP for VAP social networking site.
https://armstrongresearch.hopkinsmedicine.org/vap.aspx
CUSP is an Ongoing Process, Not an Endpoint
CUSP is an ongoing process, and is never truly finished. For example, it will be helpful to have a process to
ensure that new frontline providers, who join the unit after CUSP is underway, watch the Science of Safety
video. One strategy is to include the Science of Safety presentation in their orientation. Additionally, though
staff complete the Staff Safety Assessment in the second step of CUSP, you may consider completing the Staff
Safety Assessment on a periodic basis (e.g., quarterly) or keep the forms readily available for staff to complete
when they identify a patient safety risk.
Getting Help
We recognize that CUSP represents a lot of new material. You can access more learning materials, such as
recorded project calls and slide sets, on the CUSP for VAP Project website
(https://armstrongresearch.hopkinsmedicine.org/vap/vap.aspx). If you have additional questions, please post
them to the CUSP for VAP Project social network or email us at CUSPEVAP@jhmi.edu.
Appendices
Appendix A
CUSP for VAP Team Membership Form.
Appendix B
CUSP for VAP Team Roles and Responsibilities Form.
Appendix C
Science of Safety Training Attendance Sheet
Appendix D
Staff Safety Assessment
Appendix E
Executive Safety Rounds Kickoff Template
Appendix F
Safety Issues Worksheet for Senior Executive Partnership
Appendix G
Learning from Defects through Collective Sensemaking Tool
Appendix H
CUSP for VAP Daily Goals
Appendix I
Shadowing Another Professional
Appendix J
Briefing Tool.
Appendix K
Observing Rounds Tool
Appendix L
Barrier Identification and Mitigation Tool
References
1. Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH, Hyzy RC, Welsh R, Cosgrove SE, Sexton
JB, Colantuoni E, et al. Collaborative cohort study of an intervention to reduce ventilator-associated
pneumonia in the intensive care unit. Infect Control Hosp Epidemiol 2011 Apr;32(4):305-14.
2. Cooper M, Makary MA. A comprehensive unit-based safety program (CUSP) in surgery: Improving quality
through transparency. Surg Clin North Am 2012 Feb;92(1):51-63.
3. Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Explaining Michigan: Developing an ex post
theory of a quality improvement program. Milbank Q 2011 Jun;89(2):167-205.
4. Eliminating CLABSI: A National Patient Safety Imperative. AHRQ Publication No: 11-0037-EF, April 2010.
Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/onthecusprpt/
5. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, et
al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006 Dec
28;355(26):2725-32.
6. Sexton JB, Berenholtz SM, Goeschel CA, Watson SR, Holzmueller CG, Thompson DA, Hyzy RC, Marsteller JA,
Schumacher K, Pronovost PJ. Assessing and improving safety climate in a large cohort of intensive care
units. Crit Care Med 2011 May;39(5):934-9.
7. Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the comprehensive unitbased safety program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf
2010 Jun;36(6):252-60.
8. Wick EC, Hobson DB, Bennett JL, Demski R, Maragakis L, Gearhart SL, Efron J, Berenholtz SM, Makary MA.
Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections.
J Am Coll Surg 2012 Aug;215(2):193-200.
Appendix A: VAP Prevention Bundle
1. Identify and organize contact information for the members of your
CUSP team. Your team may not have members in every category.
Consider posting this list prominently, along with a photo of each
champion, to build enthusiasm and team cohesion.
Name & Title
Role
Phone & Email Address
Senior Executive Partner (Vice
President or above)
ICU Director / Manager
Team Leader
Physician Champion
Nurse Champion
Respiratory Therapist Champion
Physicians on team
Nurses on team
(List all)
Respitatory Therapists on team
(List all)
1.
2.
3.
4.
etc.
1.
2.
3.
4.
etc.
1.
2.
3.
4.
etc
1.
2.
3.
4.
etc.
1.
2.
3.
4.
etc.
1.
2.
3.
4.
etc
1.
2.
3.
4.
1.
2.
3.
4.
Nurse Educator
Hospital Patient Safety Officer or
Chief Quality Officer
Content Specialist
(e.g., Infectious Disease Physician;
Infection Preventionist)
Name & Title
Role
etc.
Staff from Safety, Quality or Risk
Management Office
Other team members
(Fill in role below)
2.
3.
Phone & Email Address
etc.
Appendix B: Team Roles and Responsibilities
Purpose of this tool: The purpose of this tool is to help your CUSP team think through the core tasks of
this project, and organize yourselves to get the work done. Just like clinical teams, effective improvement
teams have clearly defined roles and responsibilities. Explicit delegation helps to share leadership,
ownership, and accountability.
Please adapt this tool: A teamwork expert designed this tool to help your CUSP for VAP team anticipate
and manage project work. Please modify this tool to best fit your team’s needs. As always, we welcome
your feedback and encourage you to share your experiences with other CUSP teams in the project.
How to use this tool:
For each task:
 Think about the amount of work involved. Do you have enough people?
 Think about the type of work involved. Do you have the right skill mix?
CUSP for VAP tasks
You can break each task down into subtasks.
Project Tasks
Content and coaching calls
Who will participate in content and coaching
calls? Who will ensure staff availability?
Communicate call times to other staff members?
Logistics
Who will schedule meeting
times/locations/conference lines?
CUSP (Adaptive work) tasks
Educate staff on the science of safety
For each group of providers, who will ensure
everyone receives training?
Engaging executives
Who will be the liaison to the executive team
member ensuring participation at meetings and
presenting CUSP team updates?
HSOPS administration
Who will be in charge of ensuring high response
rates?
Staff safety assessment
Who will administer, analyze/review, and
feedback results to frontline staff?
Learning from VAPs and other defects through
sensemaking
Who will drive the investigation process and
dissemination of findings?
Implement teamwork tools
Who will lead the implementation of Daily Goals
Primary contact (initials)
Who is accountable for
moving this task forward?
Supporting roles
Who will else will be
involved and how?
Target due dates and milestones
When will tasks or subtasks be completed?
CUSP for VAP tasks
You can break each task down into subtasks.
and other teamwork and communication tools?
VAP Prevention (Technical work) Tasks
Daily Rounding Form
Who will collect and enter the daily rounding
data?
Data reporting
Who will generate reports for VAP process
measures and VAE rates?
Data feedback
Who will provide feedback to frontline providers
on VAP process measures and VAE rates? Board
of directors, hospital executives, others?
Implementation of practice changes
Who will lead efforts to align current policies with
VAP prevention bundle structural measures?
Primary contact (initials)
Who is accountable for
moving this task forward?
Supporting roles
Who will else will be
involved and how?
Target due dates and milestones
When will tasks or subtasks be completed?
Appendix C: Science of Safety Training Attendance Sheet
Clinical Area: _____________________________________
Staff member name
Date of training
Appendix D: Staff Safety Assessment
Purpose of this form: The purpose of this form is to tap into your experiences at the frontlines of patient
care to find out what risks jeopardize patient safety in your clinical area.
Who should complete this form: All staff members.
How to complete this form: Provide as much detail as possible when answering the 4 questions. Drop off
your completed safety assessment form in the location designated by the CUSP team.
When to complete this form: Any staff member can complete this form at any time.
The information requested in this box is optional and not required to complete and submit the
Staff Safety Assessment
Name (Optional):
Job Title:
Date:
Clinical Area:
Assess Risk for Harm
1. Please describe how you think the next patient in your clinical area will be harmed.
2. Please describe what you think can be done to prevent or minimize this harm.
Assess Risk for Ventilator Associated Conditions (VAC)
1. Please describe how you think the next patient will develop a ventilator-associated pneumonia (VAP).
2. Please describe what you think can be done to prevent this VAC/VAP?
Appendix E: Executive Safety Rounds Kickoff Template
Problem statement: The senior executive is a crucial member of your CUSP for VAP team. He or she has
valuable leadership and problem solving skills. Yet the senior executive may not be familiar with your clinical
area at the start of the project, and may even be intimidated by it. You can help engage your executive by
familiarizing him or her with your clinical area and your team’s safety priorities.
Purpose of this tool: You can use this tool at the beginning of your first Executive Safety Rounds to get your
senior executive up to speed. It will help you present clinical area information and safety priorities in a concise
way.
Please adapt this tool: This tool was designed to facilitate communication with their senior executive. Please
modify this tool to best fit your team’s needs. As always, we welcome your feedback and encourage you to
share your experiences with other CUSP teams in the project.
How to use this tool: The CUSP for VAP team lead or a designee should input clinical area information as
indicated in this tool. (Examples are included to show you how the tool might look when it’s completed). Make
copies of this tool and hand it out to everyone at the start of your first Executive Safety Rounds meeting. You
can refer to it as you highlight your clinical area’s characteristics and safety priorities during the meeting.
Clinical Area:
CUSP for VAP Team
Senior Executive Partner:
Physician Champion:
Nurse Champion:
Respiratory Therapist Champion
Other Champion:
List Other Team Members
1. HSOPS Assessment Composite Scores

Share your HSOPS Assessment scores with your senior executive. Examples of information you might
share are described below.
Survey Close Date:
Number of respondents:
Response Rate:
Tip: You can find the number of respondents and response rate on page 3 of your HSOPS aggregate report.

You can copy the composite scores graphs from pages 6 and 7 of your HSOPS aggregate report, below.
(The graph on page 6 looks like this):
Sensemaking Tip: Consider providing a brief summary of your HSOPS results, highlighting important points
or culture score results that you’d like to bring to your senior executive’s attention.
2. Collated Staff Safety Assessment (SSA) Responses

In Step 2 of the CUSP for VAP manual your team administered the SSA to your entire staff, and grouped
responses by commonly identified defects. You can put that information in this table to help your
senior executive get familiar with your clinical area’s safety priorities.

Consider summarizing important take-homes in one or two sentences to help your senior executive
focus on critical issues, and remember to provide your senior executive with a bit of background on the
SSA.
Prioritized Safety Issues
(Based on Collated Staff Safety Assessment Responses)
Response Category
E.g., Communication & Teamwork
E.g., Infection Control
E.g., Equipment
Total
Number
%
Staff Safety Assesment Responses

You can include some SSA responses here to give your senior executive a more nuanced understanding of your frontline staff’s perspective on safety
issues.
How the next patient will be harmed?
How will the next patient develop a VAP?
Category
Comments
E.g., Communication
& Teamwork

Ex: Lack of communication between physicians, nurses and anesthesia providers

Ex: Everyone not sharing the same information
E.g., Infection Control

Ex: Oral care with chlorhexidine is not documented well in the patient record

Ex: Non-invasive ventilatory equipment is only available through central supply.

Ex: Subglottic endotracheal tubes are not readily available on the unit.
E.g., Equipment/
Supplies
How can we prevent this harm?
How can we prevent the next VAP?
Category
Comments
E.g.,
Communication &
Teamwork

Ex: Take the completion of Daily Goals and Briefings seriously and when conduct these when everyone is available

Ex: Empower all team members to speak up when VAP process measures are being skipped.
E.g., Infection
Control

Ex: Assure that chlorhexidine is used 2 x per day for oral careEx: Assure that everyone practices good hand hygiene
before entering the patient’s room
Ex. Equipment/
Supplies

Ex: Assure that non-invasive ventilatory equipment is stored on the unit

Ex: Assure that subglottic endotracheal tubes are well-stocked in the code cart and in the supply areas
Sensemaking Tip: Consider building on staff’s suggestions for improvement with specific recommendations for your senior executive
3. Pertinent Clinical Area Information

You can include a few bullet points or graphs here with information about your clinical area that your executive
may not know. Information may include staff turnover rate, safety event rates, VAE/VAP infection rate, or other
pertinent data.
Sensemaking Tip: After completing this tool, consider supplementing it with a short
summary on the safety issues that you will be exploring in your Executive Safety Rounds.
This summary can identify your team’s objectives as you begin a partnership with your
senior executive.
Appendix F: Safety Issues Worksheet for Executive Partnership
Date of Safety Rounds:
Unit:
Attendees:
1.
5.
2.
6.
3.
7.
4.
(Please use back of form for additional attendees.)
Identified Issue
Potential/Recommended
Solution
Resources
1.
2.
3.
4.
5.
6.
7.
You can copy this form if more than 7 safety issues are identified.
Appendix G: Learning from Defects through Collective Sensemaking Tool
What is a defect? A defect is any event or situation that you don’t want to repeat. This could include an
incident that caused patient harm or put patients at risk for harm, like a patient fall.
Problem statement: If a patient is harmed in your care unit area, a typical first response is to help that
individual patient, and perhaps even blame his or her providers. This is known as ‘first order’ problem solving
because each situation is treated as if it were unique. First order problem solving focuses on the here and
now, work-arounds, and ‘quick fixes’. Too few care teams take the opportunity to learn how the defect
happened at a systems level, and how to stop it from happening again. This is known as ‘second order’
problem solving because it addresses the underlying causes of the defect.
Purpose of this tool: This tool helps you with second order problem solving. Specifically, it helps your team
organize ideas about how a defect happened, think about problems and solutions at a systems level, and
follow-up with evaluation plans to ensure your solutions worked.
Who should use this tool? You need diverse perspectives to assess and troubleshoot your care delivery
system. All staff involved in the care system that produced a defect should be present when that defect is
evaluated. At a minimum, this should include the nurse, physician, administrator, respiratory therapist and
other specialized professionals as appropriate (e.g., for a medication defect, include pharmacy staff; for an
equipment defect, include clinical engineering staff).
How to use this tool: Complete the form below for at least one defect per quarter, asking the following
questions.
I. What happened? Provide a clear, thorough, and objective explanation of what happened.
II. Why did it happen? Create a list of factors that contributed to the incident and identify whether they
harmed or protected the patient. Rate them by how severe and how common they are.
III. How will you reduce the likelihood of the defect happening again? Create a plan to reduce the
likelihood of this defect repeating. Complete the tables to develop interventions for each important
contributing factor, and rate each intervention for its strength. Choose the interventions that you will
use based on strength and feasibility. List what you will do, who will lead the intervention, and when
you will follow up to evaluate the intervention’s progress.
IV. How will you know the risk is reduced? Describe how you will know if you have reduced the risk of a
defect repeating. Survey frontline staff involved in the incident to determine whether the plan has
been implemented effectively and whether risk has been reduced.
I. What happened?
Reconstruct the timeline and explain what happened. For this investigation, put yourself in the place of those
involved – and in the middle of the event as it was unfolding – to understand what they were thinking and the
reasoning behind their actions or decisions.
I.
Why did it happen?
Investigate your care delivery system. Identify harmful and protective contributing factors at each level of your care system in the table. Harmful
contributing factors contribute to patient harm; protective factors contribute to patient safety.
System Level
Patient characteristics
Task factors
Individual Provider factors
Team factors
Work Environment
Departmental factors
Hospital factors
Institutional factors
Harmful Contributing Factor
Protective Contributing Factor
II.
How will you reduce the likelihood of this defect happening again?
Focus your efforts on the most important contributing factors. Rate each harmful contributing factor by 1)
How much it contributed to the defect, and 2) Whether it will likely show up again in the future.
Harmful Contributing Factors
Contributed to
Defect
1 (A little) to
5 (A lot)
Likely to show up again
1 (Not really) to 5
(Definitely)
Conduct a brainstorming session about interventions to address the most important contributing factors.
Refer to the Strength of Interventions Chart below for examples of strong and weak interventions. Also
consider your protective contributing factors when designing your intervention.
Strength of Interventions
Weaker Actions
Intermediate Actions
Stronger Actions

Double check

Checklists or cognitive aid

Architectural or physical plant changes

Warnings and
labels

Increased staffing or reduced
workload

Tangible involvement and action by leadership
in support of patient safety

New policy or
procedure

Redundancy



Training and
education
Enhance communication (e.g.,
check-back, SBAR)
Simplify the process or remove unnecessary
steps


Additional study or
analysis
Software enhancement or
modifications
Standardize equipment and process of care
map

New device usability testing before purchasing

Engineer forcing functions into work processes


Eliminate look-alike and soundalike drugs

Eliminate or reduce distractions
Carefully consider your resources before implementing your intervention. Determine the level of attention your intervention requires by
considering the level of support it is likely to receive, and how well the intervention addresses the contributing factor. You can use the following
table as a worksheet.
Interventions to Address the Harmful
Contributing Factor
Intervention
Addresses the Factor
1 (not well at all)
to 5 (really well)
Key stakeholders*
Level of stakeholder
support
1 (strong opposition)
to 5 (strong support)
Level of attention needed
1 (not much)
to 5 (a lot)
* Who controls resources? Who needs to have input on your intervention?
** An intervention that addresses the factor really well but has strong opposition requires a lot of attention; an intervention that addresses the factor really well and has strong support requires
less attention. You might pay some attention to an intervention that doesn’t address the factor well, if it has strong support; but probably very little attention to an intervention that doesn’t
address the factor well and has strong opposition.
Choose your interventions and develop an action plan. Improve your chances of success by anticipating and troubleshooting sources of resistance.
Finally, ensure accountability by assigning responsibility for efforts, and establish a follow-up date to evaluate intervention success.
Chosen Intervention
Anticipated sources of
resistance
Opportunities to reduce
resistance
Who’s in charge of these
efforts?
Follow-up Date
I.
How will you know the risk is reduced?
Ask frontline staff involved in the defect whether the interventions improved care. At your follow-up date,
complete the “Describe Defect” and “Interventions” sections and have staff rate the interventions. Of course,
opinions about the success of interventions are subjective. Your team will need to collect data to objectively
measure how successfully an intervention was implemented and how well it reduced the risk of a defect from
repeating.
Describe Defect:
Interventions
Intervention Was
Implemented Effectively
1 (Strongly disagree)
to 5 (Strongly agree)
Intervention Reduced the Likelihood of
Defect Repeating
1 (Not at all) to 5 (Definitely)
Appendix H: Daily Goals
Room Number _____
MD/NP COVERING Pt today:
Date ____/____/___
PM shift (7pm)
AM shift (7am)
**Note Changes from AM**
Safety
What needs to be done for patient to
be discharged from the ICU?
 Patient’s greatest safety risk?
 How can we decrease risk?
What events or deviations need to be
reported? PSN’S?
PSN
Pain goal ____/10 w/___RASS goal ___w/____
Pain Mgt / Sedation
CAM-ICU
 Daily lightening of sedation (__SAT) if not
provider should document why not
Patient Care
CAM ICU  Positive
HR Goal_______  at goal
Review EKGs
   ß Block_________
Volume status
 Net even  Net positive  Pt determined
Net goal for midnight
 Net neg:____ w/_______
Pulmonary:
Ventilator: (HOB elevated, Oral
care q4, CHG q12), SAT/SBT)
 OOB/ pulm toilet/ambulation
 wean vent (___SBT)
 Maintain current support
 mechanics by __am
 FIO2 <_____ PEEP < ____
 plan to extubate
 Wean as tol (__SBT)  Swallow Eval
 PS/Trach trial ___h x __
 Mechs before/after
SIRS/Infection/Sepsis Evaluation
 no current SIRS/Sepsis issues
SIRS Criteria
 Known/suspected infection:
 Temp > 38° C or < 36 ° C
 PAN Cx  Bld x2  Urine
 HR > 90 BPM
 Sputum  Other
 RR > 20 b/min or PaCO2 < 32 torr
 ABX changes: Initiate / D/C
 WBC > 12K < 4K or > 10% bands
Can catheters/tubes/lines be
removed/rewired? ie:foley,CL.
(___SAT)
 Negative
Cardiac


 Wean sedation for extubation in
AM
 Y  N If foley cannot be removed provider must
document a note why not
GI / Nutrition / Bowel regimen
 NPO TF Type______goal _____
(TPN line, NDT, PEG needed?)
 TPN INSULIN REQ___ Adj needed y/n
DVT:  TEDS/SCDs
Is this patient receiving DVT/PUD
prophylaxis?
 Hep q8 / q12 / gtt (protocol?)
 LMWH
PUD: PPI H2B
 N/A
Can any meds be discontinued,
converted to PO, adjusted?
 D/C:
 PO:
 Renal:
 Liver:
 N/A  Consents needed/obtained
Tests / Procedures/ OR today
Scheduled labs
 N/A
(Reassess need q12h)
To Do:
 CMP  BMP  H8 Coags ABG
AM lab needed
CXR?
Order for restraints?
 Lactate  Core 4
CXR  Ordered
Wed: Transferrin  Iron Prealb 24h urine
YN
Consultations
Does pt meet criteria for mobility protocol?
 PT/OT/SLP consult
Is the primary service up-to-date?
Disposition
Y  N
 Has the family been updated?
 Social issues addressed
(LT care, palliative care)
ICU status ___ IMC status: vitals q______
 Y  N  Family meeting today?
Y  N  N/A
Fellow/Attg Initials: ______
Nursing Initials: ______
 line change
Appendix I: Shadowing Another Professional
Problem Statement: Health care delivery is a multidisciplinary practice that requires coordination of
care among different professions and provider types. However, health care providers often do not
understand other disciplines’ daily responsibilities, teamwork, and communication issues. This disconnect
may inhibit the effective coordination of patient care.
How does shadowing another profession benefit the participant? Shadowing another provider
allows the “shadower” to gain a broader perspective of the role other professions play in patient care. The
shadower will observe communication practices, and reflect on the impact they have on collaboration and
teamwork. Shadowers can identify communication and teamwork defects that may lead to poor patient
outcomes.
Purpose of tool: This tool offers a structured approach to identify, and then improve, communication,
collaboration, and teamwork defects that impact patient care delivery.
Who should use this tool?

Staff unfamiliar with responsibilities and practice domains of another profession.
How to use this tool: Review this tool before your shadowing experience to help you recognize
important teamwork and communication issues. Use this document to identify problems observed in
patient care areas within the practice setting of the individual you are shadowing.
Spend as much time as possible within another practice domain. At the end of your shadowing experience:
I.
Review your list of observed communication and teamwork problems. Be objective and use a
systems approach to look at patient care delivery.
II.
Collaborate with the provider you shadowed to reduce communication errors and teamwork
problems that impact patient care.
III.
Prepare a draft of the problems identified and your proposed solutions. Meet with your CUSP
for VAP team to discuss your findings.
Date:
Shadowing Another Provider
I. What happened during the shadowing exercise? (Outline your observations. For this experience,
put yourself in the place of the other provider and try to view the world as he or she does.)
II. Put the pieces together. Below is a framework to help you identify communication and teamwork
issues that affect patient care and the teamwork climate in the unit. Please read and answer the
following questions.
Yes
1. Were any health care providers difficult to approach?

How did that affect the effectiveness of the health
care provider you shadowed (e.g., order ignored)?
(Write some notes, below)

What was the final outcome for the patient (e.g.,
delay in care)? (Write some notes, below)
Did this unapproachable provider detract from the
teamwork climate in the unit?
Did the provider you shadowed seem comfortable working
with this difficult provider?
2. Was one provider approached more often for patient
issues?
If yes, was it because another health care provider was
difficult to work with?

If one provider was approached more often, what
patient care issues evolved (e.g., delay in care
delivery, provider overwhelmed)? (Write some
notes, below)
3. Did you observe any error in transcription of orders by
the provider you shadowed?
4. Did you observe any error in the interpretation or
delivery of an order?
5. Were patient problems identified quickly?
No
N/A
Yes
Were they handled as you would have dealt with them?

Why or why not? (Write some notes, below)
Were there obstacles that prevented effective handling of
the situation (e.g., lack of staff, equipment)?
Did the providers involved seek help from a supervisor?
6. If you shadowed a nurse:
Was the nurse’s page or phone call returned quickly when
there was an important issue?

If yes, what was the outcome for the patient?
(Write some notes, below)
Were patient medications available to the nurse when they
were due?

If no, what was the average wait time? (Write
some notes, below)

How did the nurse react if the medication was late
(e.g., anxious, angry, upset)? (Write some notes,
below)
If the medications were delayed, could this affect the
patient’s outcome (e.g., delay in discharge)?
7. If you shadowed a physician:
Did the physician face obstacles in returning calls or pages?

If yes, what were the obstacles? (Write some
notes, below)
Did other factors affect the physician’s ability to see
patients?

If yes, what were they? (Write some notes, below)
Did the physician receive clear information or instructions?
8. If you shadowed a pharmacist:
Did the pharmacist face obstacles in dispensing on time?

If yes, what were the obstacles? (Write some
notes, below)
No
N/A
Yes
No
N/A
9. How would you assess:
Hand-offs: During the hand-off, were verbal or written
communications clear, accurate, clinically relevant, and
goal directed? (That is, did the outgoing care team debrief
the oncoming care team regarding the patient’s
condition?)

If no, explain why. (Write some notes, below)
Communication during a crisis: During a crisis, were verbal
or written communications clear, accurate, clinically
relevant, and goal directed? (That is, did the team leader
quickly explain and direct the team regarding the plan of
action?)

If no, explain why. (Write some notes, below)
Provider skill: Did the provider you shadowed seem skilled
at all procedures he or she performed?

If no, did he or she seek out a supervisor for
assistance? (Write some notes, below)
Staffing: Did staffing affect care delivery?

If yes, explain why. (Write some notes, below)
III. Now that you have shadowed a person in another profession, what will you do differently in your
clinical practice to communicate more effectively?
IV. What suggestions do you have for improving teamwork and communication?
Specific Recommendations
Actions Taken
Appendix J: Briefing Tool
Problem Statement: Communication between ICU physicians and nursing staff does not always results in efficiently and
effectively prioritization of patient care delivery and ICU admissions and discharges.
What is a Briefing? A briefing is a dialogue between 2 or more people using concise and relevant information to
promote effective communication prior to rounds in the inpatient unit.
Purpose of Tool: The purpose of this tool is to provide a structured approach to assist physicians and charge nurses in
identifying the problems that occurred during the night and potential problems during the clinical day.
Who Should Use this Tool?
 Physicians who conduct patient rounds.
 Charge nurses and nurse managers who make patient assignments and are responsible for the entire patient
population and staff within the inpatient unit.
How to Use this Tool: Complete this tool daily prior to starting patient care rounds by meeting with the charge nurse.
Briefing Process
I.
What happened overnight that I need to know about?
After an update on the patients proceed to question II unless there was an adverse event involving
one of the patients.
IF an adverse event occurred you may implement How to investigate a defect?
II.
Where should I begin rounds?
Below is a framework to help review your patient population, planned admissions and discharges.
Based on your assessment after reviewing the following questions, you should be able to identify if you
start rounds because of patient acuity or if you start rounds with the first patient to transfer out to more
efficiently prepare for the units first admission.
1. IS THERE A PATIENT THAT REQUIRES MY IMMEDIATE ATTENTION SECONDARY TO
ACUITY?
2. Which patients do you believe will be transferring out of the unit today?
3. Who has discharge orders written?
4. How many admissions are planned today?
5. What time is the first admission?
6. How many open beds do we have?
7. Are there any patient having problems on an inpatient unit?
YES/NO
NAME/ROOM
NUMBER
III.
Do you anticipate any potential defects in the day?
Problem identified
Specific things to consider?
Patient scheduling
Equipment availability/ problems
Outside Patient testing/Road trips
Physician or nurse staffing
Provider skill mix
Person assigned
to follow up
Action taken
Appendix K: Observing Rounds Tool
Problem Statement: Interdisciplinary rounds are in the best interest of patients. Communication is a root
cause of many patient adverse and sentinel events. Communication among disciplines could be improved if
viewed through the objective eye of a non-participant.
What is Observational Rounds? Observational rounds is a teamwork and communication tool to objectively
assess and improve (1) teamwork dynamics across and between disciplines, (2) identify areas where
communication could be more concise and relevant in setting daily patient goals, and (3) provide a method to
continually improve communication skills.
Purpose of Tool: The purpose of this tool is to provide a structured approach for improving teamwork and
communication behaviors across and between disciplines that negatively affect staff morale and patient care
delivery.
Who Should Use this Tool?


Physicians who conduct patient rounds.
Administrators, house officers, nurses, pharmacists, respiratory therapists, medical and nursing students
should use this tool to: (1) better understand the dynamics of multidisciplinary rounds, (2) identify defects
in communication, (3) foster collaboration among disciplines or practice domains, and (4) target areas
where communication can be improved in the rounding process and in setting patient daily goals.
How to Use this Tool: Complete this tool while observing patient care rounds. Discuss your findings with the
multidisciplinary team at the end of rounds. You may use this for one patient or the entire unit. There are
leading questions and prompts to encourage teamwork and communication assessment from a broad
perspective on the attached page.
Observation Process: Questions to consider
III.
Identify communication that was explicit (clearly stated and measurable), versus implicit
(suggested, but not clearly expressed).
a. Who was explicit in their communication?
b. Were care directives ever implied, but not clearly expressed?
If yes, by whom?
And, within which practice domain? Medicine, Nursing, Pharmacy, Dietary, Respiratory

IV.
Did anyone ask for clarification?
If yes, what team members spoke up?
Were rounds conducted in an open forum (all team members could participate and make
suggestions) or closed (led by the attending, dealt with the primary resident caring for the specific
patient)?
 If rounds were in an open forum, were team members encouraged to offer opinions/
suggestions?
 If the rounds were in a closed forum, would input from other team members benefit the
patient or the plan of care?
 Was there something missing in the patient care goals? If so, fill-in below:
Patient Room
Patient system, goal not addressed
V.
Were conflicts identified in a patient’s plan of care?
 How were the conflicts resolved?
 Was hierarchy, attending physician over resident an issue?
 Was change in plan of care supported by evidence-based medicine (literature)?
 Did the interaction style and/or communication change between providers?
VI.
Were you able to identify assertive behavior or communication?
 Was it appropriate for the situation?
VII.
Were team members able to maintain situational awareness (Aware of activities going on in the
unit)
 Where changes in the average day clearly identified?
 How were these changes resolved? Effective vs. Ineffective?
VI.
At the end of rounds, what do you wish you would have said that you did not say?
Below is a framework to help review your findings with members of the team. Based on your
observations and after reviewing the preceding questions, list any teamwork and communication
problems you identified during the course of patient rounds.
Points for Discussion with team
Problem
Team members
affected
Patient care not
addressed
Suggestions/Actions
Appendix L: Barrier Identification and Mitigation Tool
Tool Overview
Problem Statement: Guidelines summarizing evidence exist to help ensure that patients
receive recommended interventions. In addition, consistent guideline adherence may
significantly improve patient safety. However, adherence to these evidence-based guidelines
remains highly variable both within and between units, hospitals, and states. Tools to identify
factors which hinder guideline adherence (i.e. barriers) and approaches to mitigating these
barriers within individual clinical units are also lacking.
What Types of Barriers Exist? Barriers to achieving consistent adherence to evidence-based
guidelines are commonly related to provider, guideline, and system characteristics.
Purpose of Tool: Since particular barriers and the corresponding solutions may differ
between individual clinical units, the Barrier Identification and Mitigation (BIM) Tool was
designed to help frontline staffs systematically identify and prioritize barriers to guideline or
intervention adherence within their own care setting. This tool also provides a framework for
developing an action plan targeted at eliminating or mitigating the effects of the identified
barriers. By providing both a practical and interdisciplinary approach to recognizing and
addressing barriers, the BIM tool may serve as an aid to quality and safety improvement
efforts.
Who Should Use this Tool? Both frontline clinicians (e.g., physicians and nurses) and nonclinicians (e.g., unit administrator, unit support staff, hospital quality officer) within the care
setting being targeted by a particular quality improvement initiative, such as CUSP for VAP,
may utilize this tool. Frequently, BIM Team members are a subcommittee of the unit’s quality
improvement team (e.g., CUSP Team) as identified in the unit’s Background CUSP Team
Information Form. In addition, all BIM Team members should be trained in the CUSP Toolkit
and have viewed the Science of Improving Patient Safety video.
How to Use this Tool: The BIM tool is best applied within the context of a comprehensive
quality and safety improvement effort, such as CUSP for VAP. This tool should be used
periodically (every three to six months or so) to identify barriers if adherence to a guideline or
therapy is poor. This document summarizes the 5 step process and provides more detailed
explanations and sample forms for each step.
Summary of Barrier Identification and Elimination/Mitigation Process
Step 1: Assemble the interdisciplinary team: Compose a diverse team with an array of associates
from the targeted unit’s Quality Improvement (QI) Team.
BIM Team Information Form (Form 1): Gathers contact information for the BIM team members
and is completed by the designated BIM Team leader.
Step 2: Identify Barriers: Several different team members should work independently to identify and
record barriers to guideline adherence in the targeted clinical area. They should do this by way of
observing the process being impacted by the guideline, asking about this process, and actually
walking through a simulation of the process or, if appropriate, real clinical practice.
Barrier Identification Form (Form 2): Provides a framework for identifying and recording barriers,
contributing factors to barriers, and potential actions to ameliorate those barriers. Completed by
individual team members engaged in observing, asking about, or walking the process impacted by
guideline
Step 3: Compile and summarize the barrier data: Upon completion of all data collection, an
assigned team member should compile all of the barrier data recorded by the several investigators.
This team member should then summarize this information and record any suggestions provided by
observers to improve adherence.
Barrier Summary and Prioritization Table (Form 3): Template for summarizing barriers, specifying
each barrier’s relation to the guideline, identifying method of data collection, and rating each
barrier with a likelihood, severity, and priority score. Completed during team meeting.
Step 4: Review and prioritize the barriers: The Barrier Identification and Mitigation (BIM) Team
should then review and discuss the barrier summary. Next, the BIM Team should rate each barrier
on the likelihood of the barrier occurring within the unit and the severity of the barrier’s impact on
guideline adherence if it should occur. By multiplying the likelihood and severity scores together to
arrive at a priority score, the QI team will have an understanding of how imperative it is to address
each barrier.
Step 5: Develop an action plan for each targeted barrier: The BIM team should review all
suggested actions to eliminate/mitigate the selected high priority barriers. Then, the BIM team should
collectively select individual actions for the next improvement cycle based on the potential impact of
each action on the eliminating or ameliorating the barrier and the feasibility of effectively
implementing the action based on available resources. Based on these two factors, an action priority
score is calculated such that the higher the score, the higher the priority.
Action Plan Development Table (Form 4): Framework for compiling high priority barriers, potential
actions to eliminate/mitigate barriers, and evaluation measures to assess those actions.
Framework also provides mechanism to score potential actions as far as their potential impact,
feasibility and priority. This may be completed during a team meeting.
STEP 1: ASSEMBLE INTERDISCIPLINARY TEAM
First, compose a diverse team to examine a specific quality problem. This BIM Team should be a
subcommittee of the unit’s Quality Improvement (QI) Team (e.g., CUSP Team). Throughout this BIM
process, investigators will be viewing the targeted care setting as the “patient” in order to identify any
barriers to providing evidence based care that may be occurring. Thus, make sure the team is
interdisciplinary and includes members of differing levels of experience and training to more validly
characterize local barriers, develop an action plan to overcome these difficulties, and achieve
consistent guideline adherence.
Perhaps provide an open invitation to join the team at a quality improvement staff meeting or through
an email to the QI Team for the targeted care setting. Within the QI Team, encourage clinical staff
that work in the unit (e.g., physicians, nurses), support staff (e.g., unit administrators, technicians),
and content experts (e.g. hospital quality officers) to join the BIM team. Then, by group consensus,
assign team members to necessary roles and responsibilities including a chair of the BIM Team.
Brief the BIM team on the types of barriers to guideline adherence (e.g. provider, guideline or system
level), the importance of overcoming these barriers, the evidence surrounding the utility of the tool,
and on the BIM tool itself.
Additionally, all BIM Team members should be trained on the science of patient safety (e.g., having
viewed the Science of Improving Patient Safety video and be familiar with the overall process for
improving quality (e.g., reviewed the CUSP Toolkit).
List the team member names and responsibilities on the Background BIM Team Information Form
(below).
BIM TEAM INFORMATION FORM
Step 1: Assemble the Interdisciplinary Team and indicate the persons designated as BIM Team
Members (fill in as applicable). Your team may not have people in all of these categories.
ROLE
Medical director of unit
Additional Physician
Additional Physician
Nurse Practitioner/ Nurse Specialist
Nurse manager for unit
Additional nurse
Non-clinical administrator for unit
Hospital administrator
Quality improvement specialist
Human factors engineer
Technician for unit
Other unit support staff member
Other content experts
NAME & TITLE
RESPONSIBILITIES
WITHIN
BIM
TEAM
STEP 2: Identify Barriers
Several team members should work independently to identify barriers to consistent guideline
adherence in the targeted clinical area. Utilizing different modes of data collection facilitates
obtaining an accurate and complete picture of the factors influencing guideline adherence.
Observe:
 Observe a few clinicians engaged in the tasks related to the guideline.
 Remember that your role is to observe, so cause as little distraction as possible.
 Focus more on observing than documentation during the observation period. Jotting a few
notes is okay, but wait to complete the Barrier Identification Form until immediately following
the observation period.
 Along with recording the barriers to achieving consistent adherence to the guideline that were
witnessed, indicate any steps in the process that were skipped and workarounds (i.e.,
improvised process steps or factors that facilitated guideline adherence)
Discuss:
 Ask various staff members about the factors influencing guideline adherence.
 This may include informal discussions, interviews, focus groups, and brief surveys.
 Assure the confidentiality of staff responses
 Also ask staff about the problems they face and any ideas they have regarding potential
solutions for improving guideline adherence.
1) Are staff aware that the guideline exists?
2) Do staff believe that the guideline is appropriate for their patients?
3) Do staff have any suggestions to improve guideline adherence?
Walk the Process:
 Consciously follow the guideline during a simulation, or if appropriate, during real clinical
practice.
 Investigators should continue collecting data until no new barriers are identified upon new data
collection, and a comprehensive understanding of good practices and barriers to guideline
adherence is achieved. This process should take approximately 3 to 6 hours.
The investigators should record all potential reasons that clinicians were experiencing difficulties with
adhering to the guideline (i.e. guideline barriers), and factors encouraging guideline adherence (i.e.
guideline facilitators) in the Barrier Identification Form. Additionally, within the Barrier Identification
Form, investigators should indicate the method of data collection (e.g. observation, survey, focus
group, informal discussion, interview, or walking the process), the associate who collected the data,
and the clinical unit from which the data was collected.
BARRIER I DENTIFICATION FORM
Step 2: Identify Barriers to guideline adherence by observing, asking about and walking the process.
GUIDELINE:
DATA COLLECTION MODE :
INVESTIGATOR:
FACTORS
PROVIDER
Knowledge of the guideline
What are the elements of the guideline?
Attitude regarding the guideline
What do you think about the guideline?
Current practice habits
What do you currently do (or not do)?
Perceived guideline adherence
How often do you do everything right?
GUIDELINE
Evidence supporting the guideline
How “good” is the supporting evidence?
Applicability to unit patients
Does the guideline apply to the unit’s patients?
Ease of complying with guideline
How does adherence affect the workload?
SYSTEM
Task
Who is responsible for following the guideline?
Tools & technologies
What supplies & equipment are available/used?
Decision support
How often are aids available and used?
Physical environment
How does the unit layout affect adherence?
Organizational structure
How does the organizational structure (e.g. staffing)
affect adherence?
Administrative support
How does the administration affect adherence?
Performance monitoring/feedback
How does the unit know it is following the
guideline?
Unit culture
How does the unit culture affect adherence?
OTHER
UNIT:
BARRIER (S)
POTENTIAL
ACTIONS
Step 3: Compile and summarize the barrier data
Once data collection is complete, a team member should compile all of the data from the various
investigators in the above Barrier Identification Form. The information should then be summarized in
columns 1, 2, and 3 of the Barrier Summary and Prioritization Table. In column 1, briefly
summarize each barrier; in column 2, provide a brief description of the part of the guideline to which
the particular barrier pertains; then in column 3, provide the source of data collection (i.e. observation,
survey, interview, informal discussion, focus group, walking the process).
Finally, this team member records any suggestions provided by observers to improve guideline
adherence in the Framework for the Development of an Action Plan.
Step 4: Review and prioritize the barriers
As a team, review and discuss the barrier summary. Then, in columns 4, 5, & 6 of the Barrier
Summary and Prioritization Table, rate each barrier on the likelihood of the barrier occurring in the
unit (likelihood score) and the probability that it, if encountered, would lead to guideline nonadherence (severity score). Each barrier is scored from 1, indicating a low likelihood or severity, to 4,
indicating a high likelihood or severity. The priority score for each barrier is then calculated by
multiplying the likelihood and severity scores.
The higher the priority score for a barrier, the more critical it is to eliminate or mitigate the effects of
that barrier. As a team, develop your own criteria for determining which barriers to target during this
Quality Improvement cycle. For instance, you could set a priority score threshold to decide which
barriers to target (e.g. barriers with a priority score ≥ 9) or target the top 3 barriers.
BARRIER SUMMARY AND PRIORITIZATION T ABLE
Step 3 & 4: Compile, summarize, review as a team, and prioritize the barrier data collected from the investigators.
BARRIER
RELATION TO GUIDELINE
SOURCE
LIKELIHOO
D SCORE *
SEVERITY
SCORE**
BARRIER
PRIORITY
SCORE***
TARGET FOR THIS QI
CYCLE?
* Likelihood score: How likely is it that a clinician will experience this barrier?
1. Low 2. Moderate 3. High 4. Very High
** Severity score: How likely is it that experiencing this particular barrier will lead to non-adherence with the guideline?
1. Low 2. Moderate 3. High 4. Very High
*** Barrier priority score = (likelihood score) x (severity score)
Step 5: Develop an action plan for each targeted barrier
As a team, list and review the potential actions to eliminate/mitigate the selected high priority barriers
in the Framework for the Development of an Action Plan - as suggested by the observers in Step
2. Next, identify any additional potential actions using brainstorming techniques and record these in
the Framework for the Development of an Action Plan as well.
Then, collectively select individual actions for the next improvement cycle based on the potential
impact of each action on the barrier as far as improving guideline adherence (if the action is
successfully implemented) and the feasibility of effectively implementing the action based on the
resources currently available. Thus, rate each suggested action with a potential impact score and a
feasibility score. As in Step 4, each action is scored from 1, indicating a low impact or feasibility, to 4,
indicating a high impact or feasibility. The action priority score for each potential action is then
calculated by multiplying the potential impact score and the feasibility score together. Teams should
consider setting a threshold action priority score for which actions to pursue during the upcoming
quality improvement (QI) cycle.
It is critical to closely examine the feasibility of implementing an action. For example, placing a sink
within each patient’s room may increase the frequency of clinicians washing their hands, but may not
be as cost effective as placing a dispenser for hand sanitizer within each patient’s room. For each
action, the group should assign an appropriate leader, performance measures, and follow-up dates to
evaluate progress. This information should be recorded in the Framework for the Development of an
Action Plan as well.
FRAMEWORK FOR THE DEVELOPMENT OF AN ACTION PLAN
Step 5: Develop an action plan for each targeted barrier.
PRIORIT
POTEN
IZED
BARRIE
RS
TIAL
ACTION
S
POTEN
SOU
RCE
TIAL
IMPACT
SCORE
*
ACTIO
FEASIBI
LITY
SCORE *
*
N
PRIOR
ITY
SCOR
E***
SELE
CT
FOR
THIS
QI
CYCL
E?
ACTI
PERFORM
ON
LEAD
ER
ANCE
MEASURE
(METHOD)
FOLL
OW UP
DATE
*Potential impact score: What is the potential impact of the intervention on improving
guideline adherence?
1. Low 2. Moderate 3. High 4. Very high
**Feasibility score: How feasible is it to take the suggested action?
1. Low 2. Moderate 3. High 4. Very high
***Action priority core = (Potential impact score) x (feasibility score)