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© 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* 20042006 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 http://www.jhsph.edu/ctlt/training/patient_safety.html 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):33-40. 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):71-75. 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):59-68. 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):476-479.
© 2009 On the CUSP: STOP BSI Overview of STOP-BSI Program.
Small Rural/CAH Learning Community Meeting May 23, 2012 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement.
© 2011 Melinda Sawyer, RN, MSN, CNS-BC Armstrong Institute for Patient Safety and Quality The Comprehensive Unit-based Safety Program (CUSP)
Comprehensive Unit-based Safety Program (CUSP) On the CUSP: Stop CAUTI 1 Sean Berenholtz, MD MHS Johns Hopkins University Quality and Safety Research Group.
© 2009 On the CUSP: STOP BSI Implementing Daily Goals.
Small and Rural Critical Access Hospitals July 19, 2011.
Staff Safety Assessment 1. Learning Objectives To understand Step 2 of CUSP:Identify Defects To understand how to Implement the Staff Safety Assessment.
Improving ICU Care Through Teamwork Chris Goeschel RN MPA MPS
Toward Eliminating Central Line Associated Blood Stream Infections.
Seeing a Way Forward Peter Pronovost, MD, PhD Johns Hopkins University.
HAI Collaborative Meeting September 12, 2012 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement.
1 National Content Webinar CUSP: A Framework for Success March 7, 2012.
© 2009 On the CUSP: STOP BSI Senior Leadership of Quality and Safety Initiatives in Health Care.
Who We Are ~Where We are Going. Slide 2 Workshop Objectives Describe the purpose and vision of the ICU Safe Care Initiative/Comprehensive Unit-Based Safety.
© 2009 On the CUSP: STOP BSI Nurse Empowerment.
CSTS: The Cardiovascular Surgical Translational Study Senior Leadership of Quality and Safety Initiatives in Health Care Peter J. Pronovost, MD, PhD The.
Patient Safety Leadership Peter Pronovost MD PhD Professor, Schools of Medicine and Public Health Director, JHU Quality & Safety Research Group.
1 Surgical Unit-Based Safety Program Proposed Resources for Partnership for Patients Terri Conner, Ph.D. Nybeck Analytics Partnership for Patients.
Measuring Progress in Patient Safety Peter Pronovost, MD, PhD, FCCM Johns Hopkins University.
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.
Learning From Defects: An Intervention to Learn from Mistakes David A. Thompson DNSc, MS, RN Associate Professor Armstrong Institute for Patient Safety.
© 2009 On the CUSP: STOP BSI Physician Engagement.
Comparative Effectiveness Grant Toward Eliminating Central Line Associated Blood Stream Infections.
© 2009 On the CUSP: STOP BSI The Science of Improving Patient Safety.
Nurse Empowerment On the CUSP: Stop BSI. Learning Objectives To understand the importance of nurse empowerment To consider the regulatory and accreditation.
© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Taking Patient Safety to the Next Level Peter Pronovost, MD, PhD 1.
Learning Objectives 2 2 Explain the role of the senior executive in addressing technical and adaptive work Identify characteristics to search for when.
© 2009 On the CUSP: STOP BSI Nurse Empowerment Christine A. Goeschel RN MPA MPS ScD (candidate) Tennessee Center for Patient Safety December 2, 2009.
A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association September 20, 2015 Executive Briefing Drawn.
The Johns Hopkins Comprehensive Unit-based Patient Safety Program (CUSP) Peter Pronovost, MD, PhD, Johns Hopkins Univeristy.
Comprehensive Unit Based Safety Program A webinar series for QI Managers, Nurse Leaders and others supporting healthcare improvement in Wisconsin’s.
Learning From Defects. What is a Defect? Anything you do not want to have happen again.
CSTS Staff Empowerment Christine A. Goeschel ScD MPA MPS RN.
CLABSI Investigation Melinda Sawyer, RN, MSN, PCCN David A. Thompson DNSc, MS, RN.
Using CUSP as a Framework for Improving Patient Safety Steve Levy Director of Operations MHA PSO.
Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI People, Priorities, & Learning.
2 Describe the historical and contemporary context of the Science of Safety Explain how system design affects system results List the principles of safe.
11/10/20111 On The Cusp Journey: Sentara CarePlex Hospital Gail J. Rudder RN, CRNI Infection Preventionist November 10 th, 2011.
Learning Objectives 2 Identify characteristics of successful teams and barriers to team performance Understand the importance of your CUSP team Develop.
THIS PRESENTATION/PUBLICATION/ OR OTHER PRODUCT IS DERIVED FROM WORK SUPPORTED UNDER A CONTRACT WITH THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)
On the CUSP: STOP BSI Improving Situational Awareness by Conducting a Morning Briefing.
Identifying Defects Chris Goeschel June Identifying Defects What DO you know? What SHOULD you know?
Sean Berenholtz, MD MHS Learning From Defects and Implementing Daily Goals.
Science of Safety and Identifying Defects CUSP 4 MVP-VAP Content Call, Module #2.
CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Revisiting Science of Safety & Identifying Defects ARMSTRONG INSTITUTE FOR PATIENT.
Hawaii Surgical Unit Safety Program: The Journey Begins with the Comprehensive Unit-Based Safety Program May 21, 2013 Della M. Lin, M.D.
Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital.
Obtaining Results Desire Vessel Execute Culture is a vessel to cross the quality chasm.
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