3 Your patients deserve it Insurance payers demand it Why Safety and Why Now?Your patients deserve it Insurance payers demand it
4 Protect your Reputation and Reimbursement CMS monitors and reports outcomePatients have access to National DatabaseAPSF provides advisories regarding equipment, techniques and drugs.Most important: Focus on safety because you owe it to your patientsEliminate “never”eventsReduce high frequency risks.CLABSIVAP
5 Government will not pay when: A foreign object is retained within a patient´s body after surgery.The development of an air embolism within a patient´s body.A patient blood transfusion with incompatible blood.A patient´s development of stage III or stage IV pressure ulcers.Patient injuries resulting from accidental falls and other trauma
6 Government will not pay when: A patient has of poor glycemic controlA patient develops a catheter-associated urinary tract infection.A patient develops a vascular catheter-associated infection.A patient develops a surgical site infection following:A coronary artery bypass graft - mediastinitis;Bariatric surgery,Orthopedic procedures, including, but not limited to, such procedures performed on the spine, neck, shoulder and elbow.A patient develops deep vein thrombosis
7 Direct Benefits Increased Patient Satisfaction Staff engagement Collaborative teambuilding across linesLean Sigma work flow gainsFinancial rewards
9 CUSP for Patient Safety Continuous Unit Based Safety Program
10 Why the CUSP FORMAT? Improve safety culture and learn from mistakes Can be implemented throughout organizationValues the wisdom of front line staffLinked with improvement in clinical outcomesEmpowers staff to be actively involvedReduces barriers between staff and senior leadership.Armstrong Institute for Patient Safety
11 Building Your Safety Program Build a CUSPMust include ALL stakeholdersAll CUSP members have an equal sayEngage Hospital leadershipSeek type 2 solutionsMake a long term commitmentArmstrong Institute for Patient Safety
12 The Process: Assemble a CUSP Team Assess your Safety Culture Learn/Teach the Science of SafetyIdentify DefectsForm Executive PartnershipsLearn from DefectsDevelop Tools for ImprovementArmstrong Institute for Patient Safety
13 CUSP Team Members: Transdisciplinary and collaborative Team Leader Surgeon ChampionAnesthesia ChampionNursing ChampionExecutive ChampionFrontline staff (PACU, ICU, OR, Surgical floorsArmstrong Institute for Patient Safety
14 Safety Culture Formal Survey (AHRQ) HSOPS – Hospital survey of patient safetyNPSF has excellent PDF downloadcontent/uploads/2011/10/PLS_1102_SS.pdfLocal SurveyHow will our next patient be injured?What can we do to prevent it?
15 Culture versus Outcome The Health foundation, November 2011As Safety Culture increased;Readmission rates decreasedLength of ICU stay decreasedComplications decreasedMedication errors decreasedAdverse events decreasedPatient satisfaction increased
16 Science of SafetyEvery system is perfectly designed to achieve the results it getsUnderstand the principles of safe designStandardize, checklists, learn from mistakesRecognize that principles apply to technical and team workTeams make wise decisions when there is diverse and independent inputArmstrong Institute for Patient Safety
17 Identify Defects How will the next patient be injured? What can be done to prevent this harm?Surgical site infection?Production pressure?Communication?Prioritize your effortSeverity of harmFrequency of harm
18 Form Executive Partnerships Executive member is essentialStimulates discussionHelps prioritize effortsCan lobby C-Level for policy changeAccess to resourcesHelps resolve inter-department issuesMust be committed and available for safety rounds
19 Learn From Defects What Happened? Why did it happen? What did you do to reduce the risk?How do you know the risk was reduced?
20 Form Executive Partnerships Executive member is essentialStimulates discussionHelps prioritize effortsCan lobby C-Level for policy changeAccess to resourcesHelps resolve inter-department issuesMust be committed and available for safety rounds
21 Develop Tools to Improve CUSP for Safe Surgery websiteTechnical toolsBriefing/Debriefing toolsChecklistsAdaptive ToolsPerioperative daily huddleShadowing other professionals.
22 CUSP is an ongoing process, and is never truly finished. Armstrong Institute for Patient Safety
23 So…How will your next patient What will you do to prevent it? be harmed?What will you do to prevent it?