Cardiac Surgery CER Project: The Comprehensive Unit Based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture Chris Goeschel cgoesch1@jhmi.edu BNVBBVB

Immersion call Schedule Title Date /Time 13:00 EST Presented by Program Overview Feb 18, 2011 Peter Pronovost MD PhD Science Of Safety February 25, 2011 Jill Marsteller, PhD, MPP Comprehensive Unit-Based Safety Program CUSP March 4, 2011 Christine Goeschel MPA MPS ScD RN Central Line Blood Stream Infection Elimination March 11, 2011 David Thompson DNSC, MS Surgical Site Infection Elimination March 18, 2011 Elizabeth Martinez, MD, MHS Ventilator-Associated Pneumonia Reduction March 25, 2011 Sean Berenholtz, MD Hand-Offs: Transitions in Care April 1, 2011 Ayse Gurses, PhD Data we Can Count on April 8, 2011 Lisa Lubomski, PhD. Team Building April 15, 2011 Physician Engagement April 22, 2011 Peter Pronovost, MD, PhD

Learning Objectives To explain the philosophy and approach of CUSP To describe the steps in CUSP To introduce teamwork tools that help improve safety

What is CUSP? Comprehensive Unit-based Safety Program An Intervention to Learn from Mistakes and Improve Safety Culture

The Vision of CUSP The Comprehensive Unit-based Safety Program is a designed to: educate and improve awareness about patient safety and quality of care empower staff to take charge and improve safety in their work place partner units with a hospital executive to improve organizational culture and provide resources for unit improvement efforts provide tools to investigate and learn from defects Must educate staff so they have the knowledge to improve their workplace. Must be staff driven or they won’t be empowered to take charge and improve care.

The QSRG Model to Improve Care Comprehensive Unit based Safety Program (CUSP) Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Translating Evidence Into Practice (TRiP) Summarize the evidence in a checklist Identify local barriers to implementation Measure performance Ensure all patients get the evidence Engage Educate Execute Evaluate www.safercare.net Central line Associated Bloodstream Infections (CLABSI) Wash your hands prior to procedure Clean insertion site with chlorhexidine Use full barrier precautions Avoid the femoral site Ask every day if lines can be removed

The QSRG Model to Improve Care Comprehensive Unit based Safety Program (CUSP) Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Translating Evidence Into Practice (TRiP) Summarize the evidence in a checklist Identify local barriers to implementation Measure performance Ensure all patients get the evidence Engage Educate Execute Evaluate www.safercare.net Reducing Surgical Site Infections

The QSRG Model to Improve Care Comprehensive Unit based Safety Program (CUSP) Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Translating Evidence Into Practice (TRiP) Summarize the evidence in a checklist Identify local barriers to implementation Measure performance Ensure all patients get the evidence Engage Educate Execute Evaluate www.safercare.net Reducing Ventilator Associated Pneumonia

Pre CUSP Work Create a CUSP/CLABSI team Nurse, physician administrator, others Assign a team leader Measure culture in the unit* (Hospital Survey of Patient Safety “HSOPS”) Work with hospital quality leader or hospital management to have a senior executive assigned to CUSP team Discuss culture measurement with hospital association leader (how, what instrument, when)

Steps of CUSP Educate staff on Science of Safety 2. Identify defects (video download available at www.safercare.net ) 2. Identify defects 3. Assign executive to adopt unit 4. Learn from one defect per quarter Implement teamwork tools The intervention we used to improve culture and learn from mistakes is the Comprehensive unit based safety program. Pronovost J, Patient Safety, 2005

Step 1: 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 http://www.safercare.net/OTCSBSI/Staff_Training/Entries/2009/9/6_1._The_Science_of_Improving_Patient_Safety.html I have found that there are three key components to understanding the science of safety Understand that the system determines performance.

Step 2: Identify Defects Review error reports, liability claims, sentinel events or M and M conference Ask staff how will the next patient be harmed List and prioritize all defects

Step 2: Identify Defects Complete the Staff Safety Assessment

Staff Safety Assessment Results *2 answered unit is safe

Prioritize Defects List all defects Discuss with staff what are the three greatest risks Use Learning from Defect Tool to guide your efforts

Step 3: Executive Partnership Executives should become a member of CUSP teams (Surgery; ICU; Floor) Executive meets at least monthly with team review defects identified on staff safety survey work with team and develop plan to reduce risks ensure team has resources to implement plan Executive holds team accountable during monthly review of: action plans; infection data; team checkup data HSOPS (culture) data and Staff Safety Assessment data (each survey is conducted annually and results used throughout the year)

Step 4: Learning from Mistakes Select a specific defect What happened? Why did it happen (system lenses) ? What could you do to reduce risk ? How do you know risk was reduced ? Creates early wins for the project Pronovost 2005 JCJQI

Step 4: Learning from Mistakes Select a Specific Defect What happened? Why did it happen (system lenses) ? What could you do to reduce risk ? How do you know risk was reduced ? Create policy / process / procedure Ensure staff know policy Evaluate if policy is used correctly Pronovost 2005 JCJQI

What Happened? Reconstruct the timeline and explain what happened Put yourself in the place of those involved, in the middle of the event as it was unfolding Try to understand what they were thinking and the reasoning behind their actions/decisions Try to view the world as they did when the event occurred Source: Reason, 1990;

Why did it Happen? Develop lenses to see the system (latent) factors that lead to the event Often result from production pressures Damaging consequences may not be evident until a “triggering event” occurs Source: Reason, 1990;

What will you do to Reduce Risk? Develop list of interventions For each Intervention rate How well the intervention solves or reduces the problem The team belief that the intervention will be used as intended Select top interventions (2 to 5) and develop intervention plan Assign person, task follow up date

What will you do to Reduce Risk ? Safe design principles Standardize what we do Eliminate defects Create independent check Make it visible Safe design applies to technical and team work

Rank Order of Error Reduction Strategies Most Effective Forcing functions and constraints Automation and computerization Standardization and protocols Checklists and double check systems Rules and policies Education / Information Least effective Be more careful, be vigilant

Step 4 cont’d: 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

Summarize and Share Findings Summarize findings 1 page summary of 4 questions Share within your organizations Share de-identified with others in collaborative (pending institutional approval)

Identified concern from Staff Safety Assessment (CUSP Step 2) Recommended Improvements (CUSP Step 4 & 5) Interventions Implemented Risk of central line associated bloodstream infections Make sure best practices are used for all central lines insertions. A line cart and checklist is used for all central lines insertions. Risk of central line associated bloodstream infections due to poor compliance with IV tubing changes Make sure every central line IV tubing is changed according to best practice. New IV tubing labeling system used. Risk of medication errors Point of care pharmacist available on units Pharmacist assigned Poor management of pain Create guideline or protocol for pain assessment and management Pain card at every bedside Poor communication among ICU providers Create Short Term (Daily) Goals Sheet Short term goals sheet used during rounds Poor communication during ICU discharge leading to medication errors in transfer orders Implement medication reconciliation process at ICU discharge Medication reconciliation done at discharge

Improve Pain Management Educate Staff Put visual analog pain scale (VAS) card at bedside Have residents report pain scores Define defect as pain score > 3 Skip if local example is long Erdek Pronovost Erdek & Pronovost

Improve Pain Assessment Skip if local example is long

Improve Pain Management Skip if local example is long

Step 5: Teamwork Tools Daily Goals Morning Briefing J Crit Care 2003;18(2):71-75 Morning Briefing Jt Comm J Qual Patient Saf. 2005;31(8):476-9 Learning from Defects Jt Comm J Qual Patient Saf. 2006;32(2):102-8 Am J Med Qual 2009;24(3):192-5. Team Check Up Tool Jt Comm J Qual Patient Saf. 2008;34:619-623 Shadowing Jt Comm J Qual Patient Saf. 2008;34:614-8

Teamwork Climate Across Michigan ICUs The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care % of respondents within an ICU reporting good teamwork climate   No BSI 21% No BSI 44% No BSI 31% No BSI = 5 months or more w/ zero Health Services Research, 2006;41(4 Part II):1599.

CUSP Lessons Learned Culture is local Not linear process Implement in a few units, adapt and spread Include frontline staff on improvement team Not linear process Iterative cycles Takes time to improve culture Couple with clinical focus No success improving culture alone CUSP alone viewed as ‘soft’ Lubricant for clinical change

Your Role Create Unit Level CUSP teams Train all staff in the science of safety www.safercare.net Identify hazards Partner with senior executives Learn from one defect per month Try teamwork tools 33

References 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.