1. Science of Safety and Identifying Defects CUSP 4 MVP-VAP Content Call, Module #2

2. Objectives Describe the basic elements of the Comprehensive Unit-based Safety Program (CUSP) –Educate frontline staff and executives on the Science of Safety Administer the SSA and collate staff responses Be able to identify system factors that will impact whether or not the system is safe Identify the relationship between patient safety and clinical outcomes Locate CUSP resources on the CUSP 4 MVP-VAP project website

3. Comprehensive Unit Based Safety Program (CUSP) 3CUSP Tool: Phaseline Checklist 1.Educate staff on science of safety 2.Engage staff to identify defects 3.Assign executive to adopt unit 4.Learn from defects through collective sensemaking 5.Implement teamwork tools

4. Science of Safety 4 Understand the 3 Principles of Safe Design 1.Standardize work 2.Create independent checks for key processes 3.Learn when things go wrong Recognize that the principles of safe design apply to both technical and team work Teams make wise decisions when there is diverse and independent input Every system is perfectly designed to achieve the results it gets

5. Identifying Defects 5 Frontline providers understand patient safety risks in their clinical areas – They have great insight into potential solutions to these problems. The Staff Safety Assessment (SSA) helps you access this wisdom by directly asking frontline providers’ knowledge –Use it to guide your safety improvement efforts

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7. Science of Safety Assessment (SSA) 7 Collective Sensemaking –Group SSA responses by commonly identified defects Communication, equipment failure, supplies, and summarize defects (i.e., what percent of total responses were related to communication, etc.?) Prioritize identified defects –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

8. State-of-the-Practice: Then and Now http://www.defense.gov/News/NewsArticle.aspx?ID=63789

9. Identifying and Learning from Defects 9 How will you keep this from happening to you again? –When a mistake occurs, what is your gut reaction? How will you keep this from happening to someone else? –What happened? –Why did it happen? –How will the next patient develop VAP on your unit? –What do you think can be done to prevent this VAP? –How will you know the risk is reduced?

10. Adaptive and Technical Work 10 Staff need to be trained in the science of safety and the principles of safe design Motivate them to help transform their safety culture Create learning experiences –Give opportunities to turn their story into your story Use the feedback from safety surveys to engage staff and empower change –Provides the vision for where to go next!

11. Build the Foundation for Success 11 Turn Learning Into Action!! Create feedback loops –Give folks a way to say what is not working and what is working Feedback Loop –Event reports, casual conversations

12. Recap 12 Patient harm is largely preventable Change efforts often require a focus on systems, not individuals Patient safety efforts are not just about checklists; they require adaptive work and the inputs of diverse team members to succeed The five steps of CUSP bring adaptive work into the change process CUSP teams integrate the 3 principles of safe design into the day-to-day activities of their units.

13. Self-Assessment Questions 13 How do I or how will I improve the culture of safety in my unit? How do I or how will I engage frontline staff on my unit?

14. Your Next Steps: 14 By Content Call, Module 5 (April 1, 2014): 1.Watch the Science of Safety (SOS) Video –http://www.ahrq.gov/professionals/education/curriculu m-tools/cusptoolkit/videos/04a_scisafety/index.htmlhttp://www.ahrq.gov/professionals/education/curriculu m-tools/cusptoolkit/videos/04a_scisafety/index.html 2.Develop a method to deliver the SOS Video to your entire unit’s staff 3.Administer the SSA and submit aggregated results to CE 4.Facilitate at least one team meeting

15. 15 Educating Staff on SOS

16. Next Content Call 16 March 4, 2014 Pain, Agitation & Delirium (PAD)- Delirium and Sedation Management