Comprehensive Unit Based Safety Program A webinar series for QI Managers, Nurse Leaders and others supporting healthcare improvement in Wisconsin’s.

Comprehensive Unit Based

Safety Program

A webinar series for QI Managers, Nurse Leaders and others

supporting healthcare improvementin Wisconsin’s hospitals

July 2012

A Four Part SeriesPart I – July 10th

The Science of Safety and forming the CUSP teamPart II – August 7th

The Staff Safety Assessment & Safety HuddlesPart III – September 4th

Identifying DefectsPart IV – October 2nd

Learning from Defects

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Objectives for the Series

1. Understand what CUSP is and it’s components.2. Understand how to apply CUSP components in

practice.3. Understand the vital importance that a patient

safety focus has on a unit.4. Gain access to resources related to the

adoption of CUSP.

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Who is Participating in This Series?

• Any hospital enrolled in WHA’s Partners for Patients collaborative.

• QI Departments planning to adopt CUSP approaches house wide

• Units actively implementing CUSP

Disclaimer information here…

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Participation in the Webinar SeriesLevels of Participation• Level A – Learning about the CUSP model. Participants may be

QI/Risk Management or Nursing staff or leaders.• Level B - Implementing the aspects of the CUSP model as well

as completing webinar specific homework. Participants may include QI/Risk Managers and Nurses.

• Level C – Convening a Safety Team for learning and implementing the CUSP model. (Or involving an already existing Safety Team) At a minimum, Safety Team consists of CNO, Executive, Unit Manager, Physician and staff.

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Process for the Webinar Series

• Learn content through webinar– Receive follow-up materials

• Complete “next steps” from each webinar Receive mid-month check-up tool

» Intended as a reminder

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What is CUSP?

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The Vision of CUSPThe Comprehensive Unit-based Safety Program (CUSP) is a safety

culture program 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

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CUSP History• CUSP was started at Johns Hopkins Hospital in the 1990’s• Keystone project – Michigan initiative – 75 hospitals, 127

ICUs• In collaboration with Johns Hopkins Quality and Safety

Research Group• Reduce errors and improve patient outcomes in ICUs• Combination of evidence based medicine and quality

improvement• Five interventions implemented over a two year grant

funded period• Still going strong!!!!

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All Units, All the Time

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This is a Standardized approach NOT just for BSI.

STOP FALLS

STOP VAP

STOP CAUTI

• Form a unit CUSP team with executive sponsorship

• Measure unit culture• Educate staff on Science of Safety • Identify defects using the Staff Safety Assessment;

prioritize defects• Learn from one defect per quarter• Implement team/communication tools

Keep focus on this throughout the journey!!!

Why CUSP Works

• It focuses on culture.• It integrates safety practices into daily work.• It translates.• It has easier buy-in.• It brings accountability.• It keeps leaders grounded.

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Measuring Unit Culture

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Getting there isn’t easy

“The soft stuff is always harder than the hard stuff.” -- Richard Enrico,

CEO PepsiCo, 1995

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Why Focus on Culture?

• Because culture is local, it must be targeted at the unit level, with support at the organizational level.

• Frontline staff know the hazards facing their patients and are capable of identifying solutions and plans to

address specific problems.

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Safety CultureSafety Culture encompasses the attitudes held within a

workplace, from the leadership to the front lines.

This includes:• How open staff is to discussing patient safety issues and

concerns with their colleagues and their leaders• How safe they feel about speaking out if they think that a patient

is in danger• How serious they think the organizational leadership is about

patient safety• How well they think they work as a team.

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The Age-Old Question:

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How do we measure culture?

Surveys are a simple, low cost way to (sort of) measure culture. (and it’s better than not knowing anything about your culture!)

Culture Assessment• Important to measure your Safety Culture

– Examples include AHRQ Hospital Survey on Patient Safety Culture, Press Ganey’s Safety Culture Survey

• Safety Culture survey results provide insight into frontline staff’s attitudes about patient safety within your organization.

• May give some indication of staff’s actual practices around patient safety.

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Example of a Culture of Safety Survey

• AHRQ has made available the Hospital Survey on Patient Safety Culture (HSOPS) since 2004

• Comparative Data is available 2007 – 2010

• The 2010 database has 885 hospitals, and 338,607 staff responses.

• On average, hospitals submitted 383 completed surveys, for a response rate of 56%.

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Very Different from “Satisfaction”

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(But much more difficult to “fix”)

National Data Trends

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Strengths and Areas for Improvement

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Strengths for Most Hospitals Pct. Positive

Needed Improvement for Most Hospitals

Pct. Positive

Teamwork within Units 86% Non-punitive Response to Error 44%

Supervisor/Manager Expectations & Actions Promoting Patient Safety

75% Hand-offs and Transitions 44%

Overall Patient Safety Grade 74% Number of Events Reported – Hospitals Reporting NONE

53%

From the AHRQ Executive Summary

Wisconsin’s HSOPS Data

Results to be shared during live webinar

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What to do With the Results?• Analyze and share survey results with unit

staff as well as leadership.• Many hospitals take these results to their

Quality Council and/or Board of Trustees.• Use as a baseline measurement prior to

implementing CUSP.• Use as a method of focusing on

improvement/culture change.

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Forming your CUSP team

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Why Form a Team?

• One person can’t change a culture.• Need a variety of perspectives.• Leaders are removed from day-to-day

interactions.• Staff needs Leadership help to influence

change.

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CUSP Team

• Must be unit based– If you want to understand and impact unit culture

and safety the team must include front line staff

• Representation from all types of staff members who provide direct patient care on a unit

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Who to Include?• At a minimum, the following staff should be on your CUSP

team:– Team Leader/Safety– Physician – Executive Champion – Staff Nurse (ideally one from each shift)

• Other potential team members:– Nutritionist – Infection Preventionist– Quality Manager– Nurse Manager/Unit Leader– Pharmacist

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Executive Partnership• Executive sponsorship is key to the success of

the CUSP team.• Should be part of the CUSP team.• Does not have to have a clinical background

(consider asking your CFO, COO, etc).• Executive Leadership should celebrate wins and

provide encouragement, support, attention, and resources if there are set backs.

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Educating Staff on the Science of Safety

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Medical errors most often result froma complex interplay of multiple factors.

Only rarely are they due to the carelessness or misconduct of single individuals

Lucien L. Leape, MDHarvard School of Public Health

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• People are fallible• Medicine is still treated as an art, not science• Need to view the delivery of healthcare as a

science• Need systems that catch mistakes before

they reach the patient

How Can These Errors Happen?

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Why Mistakes Happen?

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• Variable input (diff pts)• Inconsistency/variation• Complexity• Too many/complicated

steps• Human intervention• Tight time constraints• Hierarchical culture

• Fatigue• Inattention/distraction• Unfamiliar situations/new

problem• Using past solutions• Equipment design flaws• Communications errors• Mislabeling/inadequate

instructions

Process Factors People Factors

SystemSystem FailureFailure LeadingLeading toto ThisThis

ErrorError

8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.9. Reason J, Hobbs A., 2000.

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Catheter pulled withPatient sitting

Communication betweenresident and nurse

Lack of protocol For catheter removal

Inadequate trainingand supervision

Patient suffers

Venous air embolism

A case study:

System Factors Impact Safety

HospitalDepartmental Factors

Work EnvironmentTeam

FactorsIndividual ProviderTask Factors

Patient Characteristics

Institutional

Adapted from Vincent BMJ

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Understand the Science of Safety• Every system is perfectly designed to achieve the results it gets

• Understand principles of safe design – standardize, create checklists, learn when things go wrong

• Recognize these principles apply to technical and team work

• Teams make wise decisions when there is diverse and independent input

How Can We Improve?

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Caregivers are not to blame

• Standardize– Eliminate steps if possible

• Create independent checks• Learn when things go wrong

– What happened?– Why?– What did you do to reduce the risk?– How do you know it worked?

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Principles of Safe Design

What Happens When We Focus on Patient Safety?

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0

10

20

30

40

50

60

70

80

90

100

% o

f res

pond

ents

with

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n IC

U re

port

ing

good

team

wor

k cl

imat

eTeamwork Climate Across Michigan ICUs

No BSI 21%No BSI 21% No BSI 44%No BSI 44% No BSI 31% No BSI 31%

No BSI = 5 months or more w/ zeroNo 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

Health Services Research, 2006;41(4 Part II):1599. 39

The Science of Safety ResourcesWebinar Follow Up Materials (will be sent out in a

follow up email)

• Link to Science of Safety video • CUSP Toolkit• Key messages for CUSP team sponsorship

– Bedside staff– Project leaders– Executive Champion

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The Science of Safety HomeworkIn the next 30 days:• Decide who should be involved in a CUSP/Safety team.• Confirm a CUSP/Safety team membership and convene the team.• To educate staff, have everyone view the Science of Safety Video.• Review culture survey baseline data or conduct a culture survey.• Plan to attend Part II (The Staff Safety Assessment & Safety

Huddles) webinar on August 7th for next steps.

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The Science of Safety Check UpMid-month Check Up

Via a web survey Questionnaire sent out on July 27th

• Did you convene a CUSP/Patient Safety team?• How many staff viewed the Science of Safety video?• Do you have a baseline safety culture?• Did the CUSP/Patient Safety team review the results of your

hospitals most recent safety culture survey results?• Were there any areas for improvement detected?• Do you have an ongoing process (informal or formal) used to

review these results?

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Additional Resources

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AHRQ Safety Survey Tools:http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm

http://www.nejm.org/doi/full/10.1056/NEJMcpc1007085

CUSP Resources: http://65.23.152.3/stop-bsi/manuals-and-toolkits/

Thank YouQuestions?

Jill Hanson & Stephanie SobczakWisconsin Hospital Association

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