Impact of Comprehensive Unit
Based Safety Program(CUSP) on
Safety Culture of Non-Intensive
Care Units
Roshan Jan Muhammad
Preceptor: Melinda Sawyer, MSN, RN, CNS-BC
Assistant Director, Patient Safety
Background

13.5% of hospitalized Medicare beneficiaries experience adverse events
during their hospital stays that include hospital associated infection,
medications errors, falls etc. Of which, 44% adverse events and related
harm events are likely preventable.
(DHHS, 2010)

More than one third of patients who sustain hospital associated adverse
events develop temporary or permanent disability and up to 20.8% of
patients die.


(Andres-Andres et al., 2009 & Zegers et al., 2009)
Safety culture has emerged as an important factor that contributes to
quality and safety of care provided and the clinical outcomes of patients
in the hospital.
(Pronovost et al., 2006; Kirwan et al., 2013;Watcher, 2008 ,
Singer et al., 2009; Mardon et al., 2010 & Sexton et al., 2006)

Joint Commission and Institute of Medicine (IOM) committee requires
health care organizations to measure and improve organization’s safety
culture.
(The Joint Commission, 2010,; Christine et al., 2010)
Safety Culture and its Significance
 “Safety culture of the
organization is the product of
individual and group values,
attitude, perceptions,
competencies, and the patterns
of behavior that determine the
commitment to, and the style
and proficiency of, an
organization’s health and safety
management”
Work
Environm
ent
Perception
about
manageme
nt
Safety
climate
Christine et al., 2010,

Determines
staffs
compliance
to policies
Chaboyer, 2013
Facilitates
professional
practice, and
error
reporting
Kirwan et al, 2013
Elements
of a
Safety
Culture
Job
satisfactio
n
Stress
recogniti
on
Measured by a valid instrument
called “Safety Attitude
Questionnaire (SAQ)”
Motivates the
engagement of
the employees
in safety
behaviors and
initiatives
Team
work
Sexton et al, (2006)
Predictor for
number of
medication
errors
reported
Contributes
to incidence
of hospital
associated
pressure ulcer,
falls, and
infections
Ausserhofer et al., 2013
Patient
satisfaction
index
CUSP and Safety Culture:
A Literature Review
CUSP: A FIVE LEGGED PROGRAM
Train staff in
the science
of safety
Engage staff
to identify
the defects
Partnership
with senior
executives
Learn from
defects
Implement
tools to
improve
communication
CUSP RELATED CLINICAL OUTCOMES
Wick, 2012;
Hong, 2013
• Decreased
(CLBSI,
SSI)
Pronovost et
al., 2005
• Improved
length of
stay
Pronovost et
al., 2006
• Reduced
mortality
Simpson et
al, 2011
• Improved
stage II
labor care
Timmel et al,
2008
• Decrease
nursing
turnover
Authors
Settings
and
sample
Team work
Climate
Safety
Climate
Job
Satisfactio
n
Working
Condition
Perception of
management
Stress
Recognition
62% vs 68%
(p < .001)
45% vs 46%
(p > .05)
Pre vs Post CUSP scores
Pronovost
et al, 2005
2 surgical
ICUs
35% vs 68%
Pronovost
et al, 2008
72 ICUs
46 % vs 50%
(P < .005).
Timmel et
al, 2010
18 beds
Surg unit
65% vs 71%
(p < .001)
Sexton et
al, 2011
71 ICUs
Vigoritto et
al, 2011
23 adult
(med/surg
ICU’s, 11
hospitals
18.4% in IG vs
6.4% decline In
CG (P <0.07)
Simpson et
al, 2011
Perinatal
teams , 11
hospitals
Saladino et
al, 2013
Piane et al,
2013
61% vs 69%
(p < .001)
61% vs 66%
(p < .001)
48% vs 55%
(p < .001)
7.5% in IG vs
3.4% in CG
(P 0.78)
25.9% in IG
vs 7.3% in
CG (P<0.07)
No
Improvement
No
improvement
No improvement
65th to 75th
percentile
48th to the
69th percentile
36th to the 54th
percentile
Nominal
improvement
22 bed CCU
No
improvement
No
improvement
No
improvement
No
improvement
No
improvement
No
improvement
144 clinical
units
> 10% or over
60% scores post
CUSP
> 10% or over
60% scores post
CUSP
42% to 52 %
(p < .001)
Key: IG (Intervention group); CG (control group); med(medical); surg(surgical)
4.5% in IG vs
6.6% decline in
CG (p 0.98)
Problem Statement and Question


Most of the CUSP successes are reported in intensive care settings.
Johns Hopkins Hospital has replicated CUSP as a quality improvement
measure in many non ICU units in over last few years to improve
patient’s safety. The impact of CUSP in adult medical surgical units is not
exclusively examined.
This outcome analysis project aimed to assess if CUSP is associated
with improvement in safety culture of adult/pediatric nonintensive care medical surgical units of Johns Hopkins Hospital.
Method



Design: retrospective cross sectional
Setting: In-patient non-critical units at JHH.
Inclusion Criteria
o In-patient CUSP units
o Implemented CUSP
between 2006-2010
o SAQ results available before
and after CUSP kick off

Exclusion Criteria
o Intensive care units
o Units merged or split
during 2006-2010
o Missing pre or post CUSP
SAQ results
Method
•
•
•
•
Sample Size: Eight non-intensive care adult/pediatric in-patient units
Data Collection and Database:
o SAQ results retrieved from vendor based soft ware “Pascal Matrix” and excel
reports.
o CUSP kick off dates of units from quality departments.
o Created a surrogate database on excel according to our project variables.
Variables
o Independent variable: CUSP
o Dependent variables: Seven safety domains of SAQ
Statistical Analysis: Paired t-test
Results
Descriptive Characteristics (n=8)
Type of units (n,%)
Adult Medical
Adult Surgical
Psych
Peds
Survey response rate % (mean, SD)
Pre CUSP
5 (63)
1 (13)
1(13)
1(13)
(n = 3)
76.99 (8.0)
Post CUSP
5 (63)
1 (13)
1(13)
1(13)
(n = 8)
81.86(15.79)
Time from CUSP to SAQ survey in months (mean, SD)
13.38 (8.34)
20.75 (4.25)
Unit specific Pre and Post CUSP Safety Attitude
Questionnaire (SAQ) Results
(%)
Units
Safety Culture
Domain
CUSP
Status
Peads
Psych
Adult
Surgical
76
Adult
Medical
1
50
Adult
Medical
2
68
Adult
Medical
3
88
Adult
Medical
4
100
Adult
Medical
5
70
Team work
climate
Pre
74
44
Post
73
66
43
80
74
96
100
84
Safety climate
Pre
61
56
64
40
68
88
96
66
Post
71
61
50
69
72
81
96
76
Pre
67
48
56
40
70
88
90
58
Post
60
66
45
69
74
96
96
97
Pre
29
52
56
36
62
48
66
66
Post
33
46
58
46
62
67
67
63
Pre
49
40
52
50
64
75
72
38
Post
62
46
48
74
66
78
69
73
Perception of
senior
management
Pre
31
26
30
36
58
61
76
30
Post
70
31
16
53
71
85
61
61
Perception of local
management
Pre
56
38
63
36
70
92
86
50
Post
78
67
47
72
81
73
87
72
Job satisfaction
Stress recognition
Working condition
Mean
(SD)
71.2
(18.2)
77.1
(17.9)
67.4
(17.6)
72.0
(13.7)
64.5
(17.8)
75.5
19.3)
51.8
(13.7)
55.1
(12.0)
55.0
(13.9)
64.4
(11.7)
43.6
(18.6)
56.0
(22.4)
61.2
(20.5)
72.0
(12.0)
Comparison of Mean SAQ Scores of Eight
Units Pre and Post CUSP (%)
Safety Culture Domains
Mean Positive
score
Pre CUSP Post CUSP
Difference
Mean
SD
Paired
t test
df
p
Team work climate
71.21%
77.15
-5.94%
18.84%
-.893
7
.402
Safety climate
67.43%
72.07
-4.64%
12.66%
-1.037
7
.334
Job satisfaction
64.58%
75.53%
-10.94%
16.95%
-1.826
7
.111
Stress recognition
51.82%
55.16%
-3.34%
7.78%
-1.213
7
.264
Working condition
55.02%
64.45%
-9.43%
13.70%
-1.948
7
.092
Perception of facility
management
43.63%
56.01%
-12.38%
19.65%
-1.782
7
.118
Perception of local
management
61.24%
72.02%
-10.78%
20.29%
-1.502
7
.177
Conclusion

CUSP has shown statistically non-significant but clinically encouraging
improvement in job satisfaction, perception of unit and senior management, team
work climate, working condition and safety climate domains of safety culture of
adult/pediatric non critical care units.

Mean score on subscale of stress recognition stands lowest pre and post CUSP
and showed a nominal increase from the baseline.

These findings are unique as none of the research has reported CUSP successes in
adult medical, psychiatric and pediatric non critical settings.
Implications for Practice


CUSP is an efficient model that can be utilized by non critical in-patient
units to positively enhance working condition, teamwork climate, job
satisfaction, safety climate of their units and to improve the perspective of
staff about leadership.
Organizations need to track other evidence based interventions to
appreciate and improve on stress recognition domain of safety culture.
Limitations






Small sample size
Convenient sample-----unequal representation from all departments
Incomplete data (SD and sample size for unit level scores, responses by
staff categories)
Inadequate control over confounding variables
Long term sustainability of the positive outcomes are not ascertained.
CUSP is a bundle intervention, thus, could not determine which
intervention works best for which domain of safety culture.
Implications for Research




Randomized control trial to establish a cause and effect relationship.
Compare CUSP with other interventions that proclaims to improve
safety culture.
Longitudinal study that evaluates if CUSP is able sustain the safety
culture scores.
Identify and test interventions other than CUSP to improve the stress
recognition domain of safety culture.
References

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
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
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
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
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
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