2. THIS PRESENTATION/PUBLICATION/ OR OTHER PRODUCT IS DERIVED FROM WORK SUPPORTED UNDER A CONTRACT WITH THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) (Contract No. HHSA290200600022, TASK ORDER # 7). HOWEVER, THIS PRESENTATION/PUBLICATION/OR OTHER PRODUCT HAS NOT BEEN APPROVED BY THE AGENCY.

3. Your Feedback Is Important! https://www.surveymonkey.com/s/9YC9D37

4. 4 CUSP Tools Name of CUSP ToolPurpose Science of Safety Training Attendance Sheet Verify participation in screenings of the “Understand the Science of Safety” educational video Staff Safety Assessment Inventory threats to patient safety that frontline care providers identify Background Quality Improvement Form (Team List) Gather names, titles, and contact information for unit safety improvement team Learning From DefectsSet up a process to learn from and respond to defects within the unit Case Summary FormAnalyze a case example of patient harm or a near-miss to identify system factors and opportunities for improvement Daily Goals ChecklistImprove team communication regarding the patient’s plan of care

5. More CUSP Tools Name of CUSP Tool Purpose Morning BriefingGet everyone on the same page at the beginning of a day or shift to set expectations and make the day more predictable Shadowing Another Professional Identify and improve communication, collaboration, and teamwork skills among different practice domains Safety Issues in the Executive Partnership Identify safety issues and recommendations for improvement identified by frontline staff in conversation with a senior executive. Status of Safety Issues Track previously identified safety issues and recommendations for improvement and status of improvement efforts Culture Debriefing Tool Provide a structured process to make culture results actionable 5

6. Learning Objectives Determine next steps for your team Review and understand the key steps of the CUSP Toolkit Review key CUSP tools Learn how Just Culture principles can augment CUSP 6

7. CUSP Toolkit Modules Introduce CUSP Assemble the Team Engage the Senior Executive Understand the Science of Safety Identify Defects Through Sensemaking Implement Teamwork and Communication Apply CUSP 7

8. Video (10-minute Conclusion video) 8

9. Assemble the Team Understand the importance of your CUSP team Develop a strategy to build a successful team Define roles and responsibilities of team members Identify characteristics of successful teams and barriers to team performance 9

10. 10 Keys to Assembling the Team Remember that culture is local Include engaged frontline providers who take ownership of patient safety Select team members with different levels of experience Include team members based on clinical intervention Hold regular meetings (weekly or monthly), set action items, and create meeting agendas Encourage input from all team members

11. 11 Assemble the Team: What the Team Needs to Do Recruit a team lead, nurse manager, physician, and executive partner along with any other team members Meet with hospital departments (risk management, quality improvement, infection prevention) to ensure that CUSP efforts are integrated into overall hospital quality improvement and patient safety efforts. List team member names and contact information on the Background Quality Improvement Form and post the form in a central location Leverage the 4Es to ensure team engagement: 1.Engage them in the process 2.Educate them about their roles 3.Execute the processes 4.Evaluate what you did

12. 12 Engage the Senior Executive Identify the main characteristics and responsibilities of the Senior Executive Understand the role of the Senior Executive in addressing technical and adaptive work Learn how to engage and hold your Senior Executive accountable Apply tactics used by leaders to engage the Senior Executive

13. 13 Keys to Engaging the Senior Executive Show how CUSP supports and leverages other improvement projects Illustrate how CUSP will increase the senior executive’s visibility Ensure that a senior executive is assigned to and meets regularly with the CUSP team Identify safety issues in the Safety Issues Worksheet for Senior Executive Partnership or a tracking log

14. 14 Engage the Senior Executive: What the Team Needs to Do The CUSP team leader or members of the safety team should meet with the senior executive before the executive holds safety rounds to share unit-specific information In preparation, gather relevant information about the unit for the senior executive During executive safety rounds, the patient safety team, senior executive, and unit providers should review any safety issues identified, particularly those related to CAUTI, and list them on a tracking log In preparation for executive safety rounds, the unit champion should:  Brief providers on the purpose of partnering with a senior executive  Ask them to be prepared to discuss their own safety concerns and suggestions for resolution during rounds

15. 15 Understand the Science of Safety Recognize the historical and contemporary context of the science of safety System design affects system results List the principles of safe design Safe design principles apply to technical and team work Teams make wise decisions when there is diverse and independent input

16. 16 Keys to Understanding the Science of Safety Develop a plan to have all staff on your unit view the Understand the Science of Safety video Make watching the video mandatory for all unit staff Create a list of who has watched the video Describe the three principles of safe design: 1.Standardize 2.Create independent checks 3.Learn from defects

17. Identify Defects Through Sensemaking Introduce tools that will help teams identify defects Introduce Sensemaking: A process of assigning meaning to ambiguous events or data Show teams how to identify defects Show how Sensemaking relates to Learning from Defects Answer each of the four questions from the Learning from Defects Tool 17

18. 18 Keys to Identifying Defects Through Sensemaking A defect is anything that you do not want to happen again The team should use the Learning from Defects Tool, which asks teams to answer these four questions: 1.What happened? 2.Why did it happen? 3.What will you do to reduce the risk of recurrence? 4.How do you know it worked? The team should: Share summaries of defects within your organization Engage staff in conversations to enhance Learning from Defects

19. 19 Identify Defects Through Sensemaking: What the Team Needs to Do The CUSP team leader, or another designee, should distribute the Staff Safety Assessment to all clinical and non-clinical providers on the unit. Safety assessments should be: Grouped by common types of defects Prioritized based on the following criteria: Likelihood of harming the patient Severity of harm Commonality Likelihood that it can be defended against in daily work Shared with the senior executive

20. Implement Teamwork and Communication Recognize the importance of effective communication Notice the barriers to communication Discover any connections between communication and medical error Identify and apply effective communication strategies from CUSP and TeamSTEPPS 20

21. The Keys to Effective Communication 21 Complete Clear Brief Timely

22. 22 Implement Teamwork and Communication: What the Team Needs to Do Identify opportunities to improve teamwork and communication by reviewing barriers the team identified while learning from a safety defect Discuss with frontline providers how and where they want to improve communication Select a tool that best addresses providers’ concerns Use teamwork and communication tools and incorporate them into team meetings and other relevant project processes

23. 23 CUSP and TeamSTEPPS Communication Strategies Daily Goals Checklist Briefing and Debriefing Shadowing another professional Handoff I PASS the BATON Check-back Call out

24. Completing the Staff Safety Assessment Step 1. Identify clinical or operational problems that threaten patient safety Step 2. Identify ways in which patients on the unit might be harmed Step 3. Determine what can be done to minimize harm or prevent safety hazards 24

25. 25 Using the Safety Issues Worksheet for Senior Executive Partnership 1.Engage the senior executive to address safety issues identified in the form 2.Use the worksheet during safety rounds to identify safety issues, potential solutions, and available resources 3.Keep the project leader apprised of the information on the worksheet

26. 26 Learning from Defects What happened?Why did it happen? What will you do to reduce the risk of recurrence? How do you know it worked?

27. 27 Using Daily Goals During morning and evening rounds, the care team should use the checklist to review the goals for the patient Once a checklist is completed, the attending signs it and gives it to the patient’s nurse to keep it at the bedside, and the team moves on to the next patient The Daily Goals Checklist should be tailored to fit your environment

28. Applying Just Culture Principles 28

29. Video 29

30. Just Culture A system that – o Holds itself accountable o Hold staff members accountable o Has staff members that hold themselves accountable 30

31. 31 Understanding Risk and Human Behavior Human Error: Inadvertently doing other than what should have been done; slip, lapse, mistake At-Risk Behavior: Choosing to behave in a way that increases risk where risk is not recognized or is mistakenly believed to be justified Reckless Behavior: Choosing to consciously disregard a substantial and unjustifiable risk

32. Managing Error and Risk 32 Human Error Product of Our Current System Design and Behavioral Choices Manage through changes in: Choices Processes Procedures Training Design Environment Console At-Risk Behavior A Choice: Risk Believed Insignificant or Justified Manage through: Removal of incentives for at- risk behaviors Creation of incentives for healthy behaviors Situational awareness Coach Reckless Behavior Conscious Disregard of Substantial and Unjustifiable Risk Manage through: Remedial action Punitive action Punish

33. Systems and Behaviors Work Together to Improve Outcomes 33 Mission, Values and Expectations System Design Behavioral Choices Improved Outcomes Learning Systems Accountability and Justice

34. 34 Engineering System Design to Support Behavior Choices Punitive Culture: Transparency is impossible Blame-Free Culture: No accountability Just Culture: Optimally supports a system of safety

35. 35 Leadership Team’s Role in Applying Just Culture Principles Have a procedure in place for employees to follow Ensure employees are properly trained Offer positive reinforcement at the monthly Learning from Defects meeting

36. Video 36

37. Video 37

38. 38 Team Members’ Role in Applying Just Culture Principles Lisa noticed that several of her patients had catheters left in place that, per the protocol, should have been removed during the prior shift Lisa used Just Culture principles to review the situation

39. Summary The seven CUSP Toolkit modules: o Introduce CUSP o Assemble the Team o Engage the Senior Executive o Understand the Science of Safety o Identify Defects through Sensemaking o Implement Teamwork and Communication o Apply CUSP When implementing CUSP for the first time, it is recommended to use the modules in this order. o For subsequent implementations, use the modules based on the unit’s needs Use the Just Culture principles in tandem with the CUSP principles 39

40. Your Feedback Is Important! https://www.surveymonkey.com/s/9YC9D37

41. References Agency for Healthcare Research and Quality. TeamSTEPPS Fundamentals Course: Module 6 Communication. Available at: http://teamstepps.ahrq.gov/abouttoolsmaterials.htm Accessed August 18, 2011. http://teamstepps.ahrq.gov/abouttoolsmaterials.htm Agency for Healthcare Research and Quality. Sensemaking. Available online at: http://dkv.columbia.edu/demo/medical_errors_reporting/site/module3 /0100-module-outline.html. Accessed August 18, 2011. http://dkv.columbia.edu/demo/medical_errors_reporting/site/module3 /0100-module-outline.html Dayton E, Henricksen K. Communication failure: basic components, contributing factors and the call for structure. Joint Commission Journal. 2007;33(1):36.