1. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Revisiting Science of Safety & Identifying Defects ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY Johns Hopkins University

2. 2 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects CUSP 4 MVP - VAP Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

3. 3 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Polling Question Who is on the call? IP – infection preventionist RN – registered nurse RT – respiratory therapist PT – physical therapist OT – occupational therapist Healthcare executive Educator National project team Other 

4. 4 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Learning Objectives 1. Review the purposes of the Science of Safety. 2. Review the importance and frequency with which the Staff Safety Assessment should be completed. 3. Making CUSP an ongoing program to empower frontline staff to improve patient safety and quality in their unit.

5. 5 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects

6. 6 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Steps of CUSP CUSP 4 MVP – VAP 1.Educate staff on the science of safety 2.Identify defects 3.Partner with a senior executive 4.Learn from defects 5.Improve teamwork and communication ADAPTIVE COMPONENTS

7. 7 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Science of Safety Patient safety is a property of systems Apply principles to both technical tasks and adaptive teamwork Teams make wise decisions when input is diverse, independent and encouraged Every system is perfectly designed to achieve the results it gets Standardize Care Create Independent Checks Learn from Defects

8. 8 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Identifying Defects Frontline providers understand patient safety risks in their clinical areas Use the Staff Safety Assessment (SSA) to tap into the wisdom of frontline providers Allow the frontline to drive your safety improvement efforts

9. 9 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Staff Safety Assessment (SSA) 1 How will the next patient in your unit or clinical area be harmed? 2 What can be done to prevent or minimize this harm? 3 How will the next patient develop ventilator-associated pneumonia? 4 What can be done to prevent this ventilator-associated pneumonia?

10. 10 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Staff Safety Assessment (SSA) Organize responses into categories –Communication –Equipment failure –Supplies Summarize defects –What percent of total responses were related to communication? –Which defects were identified the most often?

11. 11 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Staff Safety Assessment (SSA) Prioritize defects –Likelihood of the defect harming the patient –Severity of harm the defect causes –Frequency the defect occurs –Likelihood that the defect can be prevented in daily work

12. 12 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects State of the Practice http://www.defense.gov/News/NewsArticle.aspx?ID=63789 Then Now

13. 13 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Identifying and Learning from Defects How will the next patient develop VAP on your unit? 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? –What do you think can be done to prevent this VAP? –How will you know the risk is reduced?

14. 14 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Adaptive and Technical Work Train staff in the science of safety and the principles of safe design Motivate them to 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!

15. 15 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Build the Foundation for Success Turn learning into action Create opportunities for feedback –Allow staff to share what is working and what is not working Feedback loop –Debriefing –Event reports –Casual conversations

16. 16 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Recap Patient harm is largely preventable Change efforts require a focus on systems, not individuals Successful patient safety efforts require many factors –Technical checklists –Adaptive culture improvements –Inputs of diverse team members

17. 17 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Recap Use CUSP to bring adaptive work into the change process Integrate the 3 principles of safe design into daily activities –Standardize care –Create independent checks –Learn from defects

18. 18 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Self-Assessment Questions How will I improve the culture of safety in my unit? How will I engage frontline staff on my unit?

19. The CUSP 4 MVP – VAP Report Card and Next Steps CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

20. 20 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Where are we in Cohort 1?

21. 21 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Where are we in Cohort 1?

22. 22 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects CUSP 4 MVP – VAP Report Card

23. 23 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects CUSP 4 MVP – VAP Report Card Quickly asses implementation of: –Adaptive work (CUSP) –Technical work (Daily Care Processes, Early Mobility, Low Tidal Volume Ventilation)

24. 24 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Next Steps  Complete the CUSP 4 MVP – VAP Report Card. Discuss your results on upcoming coaching calls. https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/projectmanage.aspx https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/projectmanage.aspx  Use the Staff Safety Assessment to survey your staff about how to get the next patient off the ventilator faster.  Continue to attend monthly CUSP Team meetings.  Re-engage your senior executive and involve him/her in your CUSP Team meetings.  Continue working on the technical work: -Daily Care Processes -Early Mobility -Low Tidal Volume Ventilation

25. 25 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects