We think you have liked this presentation. If you wish to download it, please recommend it to your friends in any social system. Share buttons are a little bit lower. Thank you!
Presentation is loading. Please wait.
Published bySean Bowman
Modified over 2 years ago
© 2009 On the CUSP: STOP BSI The Comprehensive Unit-based Safety Program (CUSP): An Intervention to Learn form Mistakes and Improve Safety Culture
© 2009 Learning Objectives To understand the steps in CUSP To learn how to investigate a defect To understand some teamwork tools such as daily goals, AM briefing, Shadowing
© 2009 Safety Score Card Keystone ICU Safety Dashboard CUSP is intervention to improve these* How often did we harm (BSI) (median) 2.8/10000 How often do we do what we should 66%95% How often did we learn from mistakes* 100s % Needs improvement in Safety climate* 84%43% Teamwork climate* 82%42%
© 2009 Pre CUSP Work Create an ICU team – Nurse, physician administrator, others – Assign a team leader Measure Culture in the ICU (discuss with hospital association leader) Work with hospital quality leader to have a senior executive assigned to ICU team
© 2009 Comprehensive Unit-based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools Pronovost J, Patient Safety, 2005
© 2009 Science of Safety Understand System determines performance Use strategies to improve system performance – Standardize – Create Independent checks for key process – Learn from Mistakes Apply strategies to both technical work and team work Recognize teams make wise decisions with diverse and independent input
© 2009 Identify Defects Review error reports, liability claims, sentinel events or M and M conference Ask staff how will the next patient be harmed
© 2009 Prioritize Defects List all defects Discuss with staff what are the three greatest risks
© 2009 Executive Partnership Executive should become a member of ICU team Executive should meet monthly with ICU team Executive should review defects, ensure ICU team has resources to reduce risks, and how team accountable for improving risks and central line associated blood steam infection
© 2009 Learning from Mistakes What happened? Why did it happen (system lenses) What could you do to reduce risk How to you know risk was reduced – Create policy / process / procedure – Ensure staff know policy – Evaluate if policy is used correctly Pronovost 2005 JCJQI
© 2009 To Identify Most Important Contributing Factors Rate Each contributing factor – importance of the problem and contributing factors in causing the accident – importance of the problem and contributing factors in future accidents
© 2009 To Identify Most Effective Interventions Rate Each Intervention – How well the intervention solves the problem or mitigates the contributing factors for the accident – Rates the team belief that the intervention will be implemented and executed as intended
© 2009 To Evaluate Whether Risks were Reduced Did you create a policy or procedure Do staff know about the policy Are staff using it as intended Do staff believe risks have been reduced
© 2009 Teamwork Tools Call list Daily Goals AM briefing Shadowing Culture check up Pronovost JCC, JCJQI
© 2009 Call List Ensure your ICU has a process to identify what physician to page or call for each patient Make sure call list is easily accessible and updated
© 2009 AM Briefing Have a morning meeting with charge nurse and ICU attending Discuss work for the day – What happened during the evening – Who is being admitted and discharged today – What are potential risks during the day, how can we reduce these risks
© 2009Shadowing Follow another type of clinician doing their job for between 2 to 4 hours Have that person discuss with staff what they will do differently now they walked in another shoes
© 2009 CUSP is a Continuous Journey Add science of safety education to orientation Learn from one defect per month, share or post lessons (answers to the 4 questions) with others Implement teamwork tools that best meet the ICU teams needs Details of CUSP are in the manual of operations
© 2009References Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Pat Safety. 2005; 1(1): Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003; 18(2): Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2): Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):
Measuring Progress in Patient Safety Peter Pronovost, MD, PhD, FCCM Johns Hopkins University.
Learning From Defects. Slide 2 Learning Objectives To Understand the difference between first order and second order problem solving To understand how.
Seeing a Way Forward Peter Pronovost, MD, PhD Johns Hopkins University.
© 2009 On the CUSP: STOP BSI Physician Engagement.
An exemplar Chris Goeschel RN MPS MPS Johns Hopkins Quality and Safety Research Group.
The Team Check-up Tool. Slide 2 Learning Objectives To understand the tool we use to: – Describe the anticipated activities of your ICU quality improvement.
Patient Safety Research Introductory Course Session 7 Albert W Wu, MD, MPH Former Senior Adviser, WHO Professor of Health Policy & Management, Johns Hopkins.
Building Your SUSP Team Part II. Learning Objectives Define your SUSP team composition and roles and responsibilities of team members Discuss the role.
Patient Safety Research Introductory Course Session 4 Albert W Wu, MD, MPH Former Senior Adviser, WHO Professor of Health Policy & Management, Johns Hopkins.
Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group.
Partnering for Quality Creating Reliability for Healthcare Peter Pronovost, MD, PhD Johns Hopkins University.
TEAMWORK AND COMMUNICATION TRAINING. WHY WE CARE: IMPACT OF PATIENT ERROR 98,000 Americans die each year as a result of preventable medical errors*
© 2009 On the CUSP: STOP BSI Christine A Goeschel RN MPA MPS ScD (candidate) Tennessee Center for Patient Safety December 2, 2009.
UNIT-V DEFECT PREVENTION 1Defect prevention (Arun)
1. 2 PROGRAM FACULTY This program and enduring materials are aligned with Consensus Guidelines and have been developed by the Program Faculty with input.
Patient Safety Research Introductory Course Session 6 Albert W Wu, MD, MPH Former Senior Adviser, WHO Professor of Health Policy & Management, Johns Hopkins.
National Expansion Overview Spring 2010 On the CUSP: Stop BSI.
E1 Leading and creating safer health care environments: The CEO & patient safety walkabouts Gren Kershaw Chief Executive – Conwy and Denbighshire Trust.
1 Note content copyright © 2004 Ian Sommerville. NU-specific content copyright © 2004 M. E. Kabay. All rights reserved. Quality Management IS301 – Software.
March 14, 2012 Lynne Hall. Best Practice Committee looks at all Core Measure Data ◦ HF-1 Discharge Instructions is one of the lowest measure in Georgia.
Patient Safety Research Introductory Course Session 5 Albert W Wu, MD, MPH Former Senior Adviser, WHO Professor of Health Policy & Management, Johns Hopkins.
1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 4 The Leadership Role of the Licensed Practical Nurse.
MONITORING AND DOCUMENTING HIPAA PRIVACY AND SECURITY IMPLEMENTATION USING METRICS Mr. Sam Jenkins TMA Privacy Office Department of Defense.
Copyright 2011, Outcome Engineering, LLC. All rights reserved. The Just Culture Community THE JUST CULTURE CERTIFICATION TRAINING PRESENTED TO: Next Steps.
Beginning Action Research Learning Cedar Rapids Community Schools February, 2005 Dr. Susan Leddick.
Designing Safe and Effective Patient Handovers Vineet Arora, MD, MA University of Chicago Julie Johnson, MSPH, PhD University of Chicago Quality Colloquium.
Focused Review of a Sentinel Event Root Cause Analysis.
SITUATION MONITORING Attention to detail is one of the most important details... – Author Unknown SUBSECTIONS Situation Monitoring Cross-Monitoring STEP.
The School-wide PBIS& PSM/RtI Link PBIS Lead: Hannah Griesbauer PSM/RtI Coordinator: Nancy Kreykenbohm Executive Director for Special Education and Related.
1 On the CUSP: Stop BSI Two More Es and How to Spread.
© 2016 SlidePlayer.com Inc. All rights reserved.