1. 1 National Content Webinar CUSP: A Framework for Success March 7, 2012

2. 2 Today’s Speakers Marge Cannon, Medical Officer, CMS Minet Javellana, Health Insurance Specialist, CMS Barb Edson, Vice President of Clinical Quality, HRET Chris George, Director of National Projects, MHA Keystone Center Chris Goeschel, Director of Strategic Development and Research Initiatives at Armstrong Institute for Patient Safety and Quality, John Hopkins University Mary Jo Skiba, Project Manager QI/Research, Alpena Regional Medical Center

3. 3 Working Together – The Players Centers for Medicare & Medicaid Services Quality Improvement Organization (CMS QIO) Agency for Health Care Research and Quality (AHRQ) On the CUSP: Stop HAI www.onthecuspstophai.orgwww.onthecuspstophai.org CLABSI National Project Team – Michigan Health & Hospital Association - Michigan Keystone Center for Patient Safety & Quality (MHA Keystone) – Armstrong Institute for Patient Safety and Quality Johns Hopkins University (JHU) – Health Research & Educational Trust (HRET), research affiliate of the American Hospital Association

4. 4 Learning Objectives Understand CUSP impact on safety List CUSP components Describe how a hospital implemented CUSP

5. The Michigan CUSP Experience Chris George, RN MS Director of National Projects Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality

6. It is not just a simple checklist

7. 7 CUSP – The Michigan Experience Use of CUSP tied with a technical intervention, such as central line-associated blood stream infection prevention “checklist.” “Knowing the difference between adaptive and technical challenges is one of the key tasks of leadership.” Ronald A. Heifetz

8. 8 ICU Safety Climate * “Needs Improvement” - Safety Climate Score <60%

9. 9 Culture / Climate and Outcomes No BSI 21% No BSI 31%No BSI 44% No BSI = 5 months or more w/ zero The strongest predictor of clinical excellence: Caregivers feel comfortable speaking up if they perceive a problem with patient care Attribution: J. Bryan Sexton

10. 10 ICU Safety Climate * “Needs Improvement” - Safety Climate Score <60%

11. Teamwork Climate & Annual Nurse Turnover % reporting positive teamwork climate High Turnover 16.0% High Turnover 16.0% Low Turnover 7.9% Low Turnover 7.9% Mid Turnover 10.8% Mid Turnover 10.8%

12. “The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.” Man and Superman George Bernard Shaw

13. 13 The Comprehensive Unit-based Safety Program The Comprehensive Unit-based Safety Program (CUSP): An Intervention to Learn from Mistakes and Improve Safety Culture Chris Goeschel, ScD MPA MPS RN FAAN Director, Strategic Development and Research Initiatives at Armstrong Institute for Patient Safety and Quality Johns Hopkins University

14. 14 Ideas for Ensuring Patients Receive the Interventions: the 4Es Engage: Stories, show baseline data Educate staff on evidence Execute – Standardize: Create line cart – Create independent checks: Create BSI checklist – Empower nurses to stop takeoff – Learn from mistakes Evaluate – Feedback performance – View infections as defects

15. Ensure Patients Reliably Receive Evidence SeniorTeam Staff leaders Engage How does this make the world a better place? Educate What do we need to do? Execute What keeps me from doing it? How can we do it with my resources and culture? Evaluate How do we know we improved safety? Pronovost: Health Services Research, 2006

16. 16 Measure Have We Created a Safe Culture? How Do We Know We Learn From Mistakes? CUSP Comprehensive Unit-based Safety Program 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools How Often Do We Harm? Are Patient Outcomes Improving? (TRiP) Translating Evidence Into Practice 1.Summarize the evidence in a checklist 2.Identify local barriers to implementation 3.Measure performance 4.Ensure all patients get the evidence Improve

17. 17 What is CUSP? Comprehensive Unit-based Safety Program An intervention to learn from mistakes and improve safety culture www.onthecuspstophai.org

18. BSI-Reduction Protocol -Best-evidence supplies, organization of supplies -Ensuring all patients receive the best practices -Checklist to ensure consistent application of evidence Comprehensive Unit-based Safety Program (CUSP) -Improve or reinforce good cross- disciplinary communication and teamwork -Enhance coordination of care -Address overall patient safety -Work towards healthy unit culture On the CUSP: Stop BSI Intervention

19. Pronovost, Berenholtz, Needham BMJ 2008

20. 20 Safety Score Card Keystone ICU Safety Dashboard 20042006 How often did we harm (BSI)? (median) 2.8/10000 How often do we do what we should? 66%95% How often did we learn from mistakes?* 100s Have we created a safe culture? What areas need improvement? Safety climate* 84%43% Teamwork climate* 82%42% * CUSP is intervention to improve these

21. 21 Pre CUSP Work Create a CUSP team – Nurses, physician, support staff, infection preventionist – Assign a team leader Measure culture in the unit Work with hospital quality leader or hospital management to have a senior executive assigned to CUSP team

22. 22 Steps of CUSP 1.Educate staff on science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools Pronovost J, Patient Safety, 2005

23. 23 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 teamwork Recognize teams make wise decisions with diverse and independent input

24. 24 Step 2: Identify Defects Administer the staff safety assessment and ask staff, “How will the next patient be harmed?” Review error reports, liability claims, sentinel events, or M and M conference

25. 25 Prioritize Defects List all defects Discuss with staff what are the three greatest risks and what you should work on first

26. 26 Step 3: Executive Partnership Executive should become a member of unit team Executive should meet monthly with unit team Executive should – – Review defects – Ensure unit team has resources to reduce risks – Hold team accountable for improving risks and central line- associated blood steam infection rate

27. 27 Step 4: Learning from Mistakes 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, or procedure – Ensure staff know policy – Evaluate if policy is used correctly Pronovost 2005 JCJQI

28. 28 Step 4 cont’d: Identify Most Important Contributing Factors Rate each contributing factor – Importance of the problem and contributing factors In causing the accident In future accidents

29. 29 Step 4 cont’d: Identify Most Effective Interventions Rate each intervention – How well the intervention solves the problem or mitigates the contributing factors for the accident – Rate the team belief that the intervention will be implemented and executed as intended

30. 30 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

31. 31 Step 5: Teamwork Tools Call list Daily goals Morning briefing Shadowing Culture check up Pronovost JCC, JCJQI

32. 32 Step 5 cont’d: Call List Ensure your unit has a process to identify which physician to page or call for each patient Make sure call list is easily accessible and updated

33. 33 Step 5 cont’d: Morning Briefing Have a morning meeting with charge nurse and unit attending(s) about the unit-level plan for the day Discuss work for the day – What happened during the evening – Who is being admitted and discharged today – What are potential risks during the day; how can we reduce these risks

34. 34 Step 5 cont’d: Shadowing Follow another type of clinician doing his or her job for between 2 and 4 hours Have the shadower discuss with staff what he or she will do differently now that he or she has walked in another person’s shoes

35. 35 CUSP is a Continuous Effort Add science of safety education to orientation Learn from one defect per quarter; share or post lessons Implement teamwork tools that best meet the unit’s needs Review details in the CUSP manual

36. 36 Action Items -- CUSP Look over the CUSP manual with team members Brainstorm potential hazards with team Assess team composition with respect to CUSP elements Review pre-implementation checklist — where are you?

37. 37 Action Items Review content of Web site at www.onthecuspstophai.orgwww.onthecuspstophai.org Toolkits Slidesets Manuals Project Management Checklists – Pre-Implementation Checklist – CEO/Senior Leader Checklist – Infection Preventionist Checklist

38. 38 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, et al. 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, et al. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):476-479.

40. CUSP + CAUTI Process and Prevention Mary Jo Skiba, RN BSN Project Manager QI/Research 40

41. Objectives Apply CUSP interventions to CAUTI project Remove barriers/identify steps to successful CAUTI project initiation Use CUSP to maintain success 41

42. Science of Safety Education Education done prior to CAUTI Safety survey to identify at-risk departments Mandatory science of safety training 42

43. Project Planning CAUTI Team Policies Awareness campaign Data collection plan Project start date Education Plan for follow-up 43

44. Project Planning Establish and engage CAUTI team members –Involve frontline staff – Respect the wisdom –Have a physician champion –Include charge nurses/staff development –Engage an executive leader Identify defects –Review baseline data – CAUTI rate –Brainstorm safety concerns –Determine the scope of your initial project Policy - Urinary catheterization –Review, revise, consolidate –Use policy in toolkit –Don’t re-create the wheel 44

45. Project Awareness KEYSTONE HAI (Hospital Associated Infections) “Bladder Bundle Project” Preventing Catheter- Associated Urinary Tract Infections Hospital newsletter Fliers Screen savers 45

46. Data Collection Data collectors Data forms – Add qualifiers specific to your hospital Ensure understanding of project requirements 5 days week – Monday through Friday (not weekends) Data entry with Web-based program 46

47. Planning Education Identify Defects -- Plan Ahead to Prevent Roadblocks Nursing Who will be trained Who will train How will we train When will we train How will we do makeups How much ongoing training or re-training needed Physicians Who will train How will we train When will we train 47

48. Educate on the Evidence 1.Didactic CAUTI face-to-face inservice All nursing/aides Guideline for prevention of CAUTI Physician CME Department meetings 2. Demonstration of insertion competency 48

49. Developing CAUTI Education Don’t re-create the wheel Use other hospitals’ PowerPoint slides Multiple CAUTI toolkits Update/revise to fit 49

50. 50 CAUTI Education Trained the trainers Engaged frontline staff

51. Urinary Catheter Insertion Competency Traveling mannequin 100 percent of aides and all nurse frequent inserters (ED, OR, WHU, IP rehab, ICU) Read policy Take quiz Perform procedure Instant remediation and repeat demonstration 51

52. Evaluate - Learn from Defects 167 Competencies Average 15 min/staff member 41 aides, 126 nurses Improper cleaning26 Improper gloving24 Contaminated field45 Didn’t know needleless 30 cath port for specimens 52

53. Execute New Plan Improvement plan for competency Require field competency all aides within 2 months, supervised by RNs Newly hired aides trained by RNs Yearly aide hands-on demo of competency 53

54. Other Strategies Caths flagged with date of insertion Secured to legs Specimen collection for culture -Don’t use first urine drained from catheter -ED patients – Prior to collection, change catheter unless known change within 7 days -Inpatients – If catheter in for 7 days must change prior to specimen collection Perineal hygiene prior to cath “John Door” educational posters 54

55. Outcome = Culture Change 3.25 CAUTI’s/Month 1.17 CAUTI’s/Month

56. Identify Why Defects - CAUTIs Cath competency plan not followed Focus was on EMR implementation Daily cath patrol not consistent Prevalence rates up

57. Execute New Plans Annual competency aide and ED/OR nurses Imbedded competency orientation/annual skill evaluations Agenda item every leadership/staff meeting Charge nurse daily cath patrol Feedback monthly staff and physicians 57

58. Execute New Plans Build cath necessity into EMR Consider decrease size standard cath - #16 to 14 ED data capture of cath necessity 58

59. CUSP - Not a Linear Process “You might have to fight the battle more than once in order to win it.” (Margaret Thatcher) Don’t worry alone. CUSP is a team sport. “Shoot for the moon. Even if you miss, you'll land among the stars.” (Les Brown) Questions? mjskiba@agh.org 59

60. Polling Questions 1) Have you ever heard of the Comprehensive Unit-based Safety Program (CUSP) before? –I have never heard of CUSP –I have heard of CUSP, but have not implemented it –I have heard of CUSP, but have not successfully implemented it –Have implemented CUSP successfully and actively using it in my unit 2) My senior executive regularly attends safety meetings on my unit, and can identify the top three safety issues that our safety team is currently working on: –Very rarely attends and is out of touch with our unit safety issues –Intermittently attends, and is somewhat aware of our unit safety issues –Attends whenever possible, and is aware of our unit’s top three safety issues 3) By ensuring that your senior executive is a part of your safety team, meeting monthly with your unit team, and holding your unit team accountable for improving risks surrounding a hospital inquired condition, my unit will be successfully utilizing the executive partnership component of CUSP? –No, not at all –Not sure –Yes, those are the main elements of the executive partnership component of CUSP 60