1. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Content 1: 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 Describe the basic elements of the Comprehensive Unit- based Safety Program (CUSP) –Educate frontline staff and executives on the Science of Safety –Administer the Staff Safety Assessment (SSA) and collate staff responses Identify system factors that will impact safety Describe the relationship between patient safety and clinical outcomes Locate CUSP resources on the CUSP 4 MVP-VAP project website

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

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)

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. 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 Homework By your next coaching call: 1.Watch the Science of Safety (SOS) Video –http://www.ahrq.gov/professionals/education/curriculum- tools/cusptoolkit/videos/04a_scisafety/index.htmlhttp://www.ahrq.gov/professionals/education/curriculum- tools/cusptoolkit/videos/04a_scisafety/index.html 2.Plan how to deliver the SOS video to all staff members 3.Administer the SSA and submit aggregated results to CE 4.Facilitate at least one team meeting

21. 21 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects Training Steps and Tools NEXT STEPTOOLS TO USE Educate CUSP team on science of safety Science of Safety video Record staff that completes training Science of Safety training attendance sheet Administer SSAStaff Safety Assessment Hang Science of Safety factsheet in break room, rest room, etc. Science of Safety factsheet Collate results of SSA and share with CUSP team Reference this presentation for help with sharing results

22. 22 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects DATETOPIC Feb 18, 2015–Spontaneous Awakening and Breathing Trials –Utility of the Exposure Receipt Assessment Mar 18, 2015–Delirium Assessment Training –Benefits of Subglottic Endotracheal Tubes Apr 15, 2015–Daily Goals Facilitates VAE Prevention –Implementation Assessment Overview May 20, 2015–Early Mobility: A Practical Approach June 17, 2015–Learning from Defects Upcoming Content Sessions Third Wednesday of each month from 11:00 am – 12:30 pm EST

23. 23 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects DATETOPIC Feb 4, 2015–Completing the Exposure Receipt Assessment –Preliminary Structural Assessment Data Reports Mar 4, 2015–Intro to Objective Outcome Measures Mar 11, 2015*–Understanding Your HSOPS Data & Reports –Debrief Your Safety Culture Results Apr 1, 2015–Defining the Daily Early Mobility Measures May 6, 2015–Strategies for Collecting and Entering Early Mobility Measures June 3, 2015–Assessing Your Exposure Receipt Assessment Data Reports Upcoming Data Sessions First Wednesday of each month from 11:00 – 12:00 pm EST

24. 24 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects DATETOPIC Jan 28, 2015–VAE Surveillance Training: An Overview Feb 25, 2015–VAE Surveillance Training: Infection-related Ventilator- associated Complication (IVAC) Mar 25, 2015–VAE Surveillance Training: VAP (PVAP) Upcoming IP Sessions Fourth Wednesday of Jan, Feb and March from 11:00 am – 12:00 pm EST

25. 25 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects CUSP 4 MVP – VAP Website Visit: https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx

26. 26 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects What Can I Find on the CUSP 4 MVP – VAP Website? CUSP Tools and Guides HSOPS Resources Data Collection Tools Educational Materials –Toolkits –Literature Reviews –Fast Fact Sheets Archive of webinars led by subject matter experts

27. 27 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsContent: Science of Safety & Identifying Defects