Transcript Slide 1

The Comprehensive Unit-Based Safety
Program (CUSP)
Culture, Teamwork, and Clinical Improvement
Armstrong Institute for Patient Safety and Quality
Presented by: Melinda D. Sawyer, MSN, RN, CNS-BC
Assistant Director, Patient Safety
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
Objectives
• Explain the relationship between patient
safety culture, CUSP, and clinical outcomes
• Describe the foundational elements of the
CUSP program
• Identify the 5 steps of CUSP
• Describe how staff empowerment and role
modeling will support positive culture
2
Armstrong Institute for Patient Safety and Quality
RAND Study Confirms Continued Quality
Gap
Condition
Percentage of
Recommended Care Received
Low back pain
68.5
Coronary artery disease
68.0
Hypertension
64.7
Depression
57.7
Orthopedic conditions
57.2
Colorectal cancer
53.9
Asthma
53.5
Benign prostatic hyperplasia
53.0
Hyperlipidemia
48.6
Diabetes mellitus
45.4
Headaches
45.2
Urinary tract infection
40.7
Hip fracture
22.8
Alcohol dependence
10.5
McGlynn et al, NEJM 2003; 348(26):2635-26453
What Are Core Aspects of
Safety Culture…
Formal and
informal leader
actions &
expectations
Teamwork
processes
(e.g., back-up
behavior)
Feedback,
reward, and
corrective
action practices
Communication
patterns &
language
Resource
allocation
practices
Culture
of
Safety
Error-detection
and correction
systems
4
Armstrong Institute for Patient Safety and Quality
Culture Change is Hard Because
Culture has Three Layers…
(Schein, 2010; Scorzoni, 1982)
1. Behaviors, norms, processes
enacted on the job, feedback &
reward systems
2. Espoused values, goals,
philosophies, formal
policies
3. Underlying
assumptions
5
Armstrong Institute for Patient Safety and Quality
Culture Change is Hard Because
Culture has Three Layers…
(Schein, 2010; Scorzoni, 1982)
1. Behaviors, norms, processes
enacted on the job
Safety climate surveys
focus diagnostic
measurement here
2. Espoused values, goals,
philosophies, formal
polices
3. Underlying
assumptions
6
Armstrong Institute for Patient Safety and Quality
Culture Change is Hard Because it
Involves both Unlearning and Re-Learning
Refreeze
Learn &
Rebalance
Unfreeze
Motivation to change
Disconfirming information
Creating psychological safety to overcome
change anxiety
Lewin, 1951;
7
Schein, 2009
Culture Change is Hard Because it
Involves both Unlearning and Re-Learning
Refreeze
Learn &
Rebalance
Unfreeze
 Learning new concepts & standards
 Reframing & reinterpreting old
 Imitation and identification with
roles models
 Trial-and-error learning
Lewin, 1951;
8
Schein, 2009
Culture Change is Hard Because it
Involves both Unlearning and Re-Learning
Refreeze
Learn &
Rebalance
Unfreeze
 Internalize new
concepts, meaning,
and standards
 Incorporate into
normal operations
& crisis events
Lewin, 1951;
9
Schein, 2009
Best Practices for Promoting a Culture of
Safety
Most effective driver of safety culture = Salient leadership
and peer commitment to safety as #1 priority
1. Align espoused values and actual practices
 Prioritize safety in business decisions
 Articulate vision in terms of desired behaviors
2. Engage and create ownership among frontline team
members
 E.g., Learning from defects, investigating most common
workarounds
3. Increase visibility around safety
 Safety walkrounds, townhalls
4. Deliberate role modeling & coaching
Armstrong Institute for Patient Safety and Quality
10
Best Practices for Promoting a Culture of
Safety
5. Clearly define and reinforce expectations regarding
behaviors and attitudes
 Empower all staff to stop the line
6. Build reporting structures that engage continuous
learning & improvement
 Feedback & transparency (response of leadership and
peers matters)
7. Create a common language and dialogue often about
safety
 Standardize communication that facilitates learning
and identification of glitches/concerns (e.g., briefing,
11
debriefing) Armstrong Institute for Patient Safety and Quality
Interventions to Promote Safety Culture:
Systematic Review
(Weaver, Dy, Lubomski, Wilson, in press)
• 2750 articles  133 full review18 included
• 61% = multi-faceted interventions
– 33% included team-training
– 22% included executive walkrounds
– 22% included comprehensive unit based safety
program (CUSP)
• 50% significantly improved safety culture survey scores
• 40% also reported other outcomes
• Rates of reported errors resulting in pt. harm (Abstoss et al., 2011)
• Rates of RRS activations that resulted in codes (Donahue, 2011)
• Adverse outcomes (Riley, et al., 2011)
12
Armstrong Institute for Patient Safety and Quality
CUSP:
Comprehensive Unit-based Safety Program
CUSP = A safety improvement strategy that integrates
communication, teamwork, and leadership to create and
support a culture of patient safety that can prevent harm,
and improve clinical processes and outcomes.
Using CUSP Tools to Improve
Patient Safety Culture
(For Clinical Areas With < 60% Agreement)
TEAMWORK CLIMATE









Morning/Shift Briefings
Daily Goals
Shadowing Exercise
OR Briefings
SBAR
Simulation
Team Training
Culture DebriefingTool
Reach out within this hospital
• Consult with other clinical areas that
have 80% teamwork climate or higher,
as they have a consensus of
excellence
SAFETY CLIMATE
 Executive Partnership Training
• Use this for your lowest scoring clinical areas
first, as it is a powerful intervention, more
targeted than traditional executive walkrounds
 Hero Form (Feedback from Frontline
Workers)
 Root Cause Lite
 Science of Safety Training
• 45 Minute online course; free registration is
required
• Culture Debriefing Tool
Reach out within this hospital
• Consult with other clinical areas that have
80% safety climate or higher, as they have
a consensus of excellence
14
How does CUSP Contribute to a
Culture of Safety?
• Designed to improve safety culture and help
staff learn from mistakes
• Integrates safety practices into the daily work of
a unit or clinical area
• Provides a scalable intervention
– Can be implemented throughout the hospital
or organization
• Draws wisdom from frontline staff to fix hazards
– Creates the forum necessary to speak up
• Empowers staff to improve safety culture
What are the foundational elements
of CUSP?
•
•
•
•
Focus on systems, not individuals
Value communication and teamwork
Value infrastructure and support
Accept responsibility for the systems in which
we work
• Recognize that culture is local
• Respect transparency
CUSP
Pre-CUSP
CUSP
1.
Conduct a Culture
Assessment
1. Train Staff in the Science of
Safety
2.
Establish an
Interdisciplinary CUSP
Team
2. Engage Staff to Identify
Defects
3.
Identify a Senior
Executive
3. Senior Executive
Partnership/Safety Rounds
(Kick-off Meeting)
4.
Gather Unit Information
4. Learn from Defects
5. Implement Tools for
Improvement
Who is essential to the CUSP Team?
Frontline
Staff
Patient Safety
Coordinator/P
atient Safety
Officer
Senior
Hospital
Executive
CUSP
Nurse
Manager
CUSP Coach
CUSP Unit
Champion
Physician
Champion
18
Armstrong Institute for Patient Safety and Quality
CUSP – Step 1- Train Staff in the
Science of Safety
Science of Safety Training principles:
• Understand that safety is a property of systems
• Identify principles of safe design (standardize, create
independent checks, learn from mistakes)
• Understand that teams make wise decisions with diverse
and independent input
• Recognize that principles of safe design apply to both
technical and team work
CUSP – Step 2 – Identify Defects
Defect = anything the you don’t want to happen
again!
• Staff Safety Assessment- all staff are asked
to identify:
– How will the next patient will be harmed?
– What can we do to prevent that harm?
• Use defects identified in the event reporting
system
• Use results from your culture assessment
scores and debreifings
Armstrong Institute for Patient Safety and Quality
20
CUSP – Step 3 – Executive
Partnership
Senior Executive Partnership:
• Goal = bridge the gap between senior management
and frontline staff
• The role of the senior executive is one of advocacy
and action in support of the unit’s safety efforts
• The executive is encouraged to discuss safety
issues, help to remove barriers, and implement
improvement efforts
CUSP – Step 4- Learn from
Defects
Learning from Defects tool:
1. What happened?
2. Why did it happen?
3. What did you do to reduce risk?
4. How do you know risks have been reduced?
What Will You Do to Reduce the
Risk?
• Safe design principles
– Standardize what we do
− Eliminate defects
– Create independent checks
– Make it visible
• Safe design applies to technical and team work
23
© JHU and JHHS, 2011
Error-Proofing Strategies
Eliminate
Replace
Prevent error
from occurring
Prevent
Facilitate
Error-Proofing
Minimize harm
resulting from
error
Detect (and
correct)
Mitigate
24
© JHU and JHHS, 2011
Six “Error-Proofing” Strategies
( in order of effectiveness)
Strongest 1. Eliminate - eliminate the task or part
2. Replace - use a more reliable process
3. Prevent - engineer so mistakes harder to
make
4. Facilitate - make work easier to perform
correctly
5. Detect - make mistakes more visible
6. Mitigate - minimize the effects of errors
Weakest
© JHU and JHHS, 2011
25
Preventing the Error from Occurring
• Eliminate
Source: www.mistakeproofing.com
Eliminate the step of turning headlights on and off…
Spawned from accidents that occurred because people forgot to
turn lights on going through tunnels
© JHU and JHHS, 2011
26
Preventing the Error from Occurring
• Replace
Smart Infusion Pumps
27
© JHU and JHHS, 2011
Preventing the Error from Occurring
)
•
•
•
•
Color coding
Geometric shapes
Pins
Labeling
Many Poka-Yoke ideas are the result of preventing a
recurrence of an error/harm that has occurred.
28
© JHU and JHHS, 2011
Preventing the Error from Occurring
• Prevent
Air and Oxygen valves will only fit in their corresponding outlets.
All of the gas valves have a pin at 12 o’clock, the other pin differs in location.
The second pin for medical air is at 4 o’clock
29
© JHU and JHHS, 2011
Preventing the Error from Occurring
• Facilitate
Source: www.mistakeproofing.com
Makes it easier to follow at a safe distance
30
© JHU and JHHS, 2011
Preventing the Error from Occurring
• Facilitate
31
© JHU and JHHS, 2011
Preventing the Error from
Occurring
Facilitate
TALLman lettering to differentiate LASA meds
(look alike, sound alike)
32
© JHU and JHHS, 2011
Minimize the Harm from Error
• Detect
Source: www.mistakeproofing.com
33
© JHU and JHHS, 2011
Minimizing the Harm from Error
• Mitigate
Source: www.mistakeproofing.com
Source: www.500sec.com
34
© JHU and JHHS, 2011
Facilitation vs. Prevention
• Facilitation
• Prevention
Source: www.mistakeproofing.com
35
© JHU and JHHS, 2011
Rank Order of
Error Reduction Strategies
Eliminate
Forcing functions and constraints
Eliminate
Automation and computerization
Replace
Standardization and protocols
Replace
Checklists and double check systems
Facilitate
Rules and policies
Facilitate
Education / Information
Facilitate
Replace
Facilitate
Be more careful, be vigilant
© JHU and JHHS, 2011
Facilitate 36
CUSP Step 4: Learning from DefectsSummarize and Share Findings
• Summarize findings (Case Summary)
• Share within your organization
• Share de-identified findings with other organizations
37
© JHU and JHHS, 2011
CUSP – Step 5- Implement
Teamwork Tools
Tools to improve:
1. Daily Goals Checklist
2. Morning Briefing
3. Observing Rounds
4. Shadowing another Profession
5. Culture debriefing Tool
6. Physician Call List
CUSP IMPROVING CULTURE,
CLINICAL PROCESSES, AND
OUTCOMES
39
Armstrong Institute for Patient Safety and Quality
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 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
Rate/1,000 Catheter days
ICU Catheter-Associated
Bloodstream Infections
30
Education
Line Cart
Checklist
20
10
NHSN Mean
0
Risk of Medication Errors
• Pharmacist participation on daily rounds in the ICU associated
with:
– 66% reduction in adverse drug events (ADEs)
– ADEs reduced 10.4/ 1000 pt days to 3.5
– Prevent one ADE every 143 patients
Leape
• Required significant resources
– Executive partner was able to obtain the required resources for 1st
ICU
– Pharmacists are now assigned to every inpatient unit at JHH.
• Survey conducted in 2009 to Dept. of Medicine nurses showed
unit-based pharmacists were rated #1 improvement in
medication safety
STAT Medication Process Delays
• Same survey conducted in 2009 revealed #1
concern with medication safety was delays in
STAT medications
• Engaged interdisciplinary Lean Sigma team
to reduce waste and improve consistency of
process
• Intervention: Add 45 frequently ordered STAT
medications to the medication Pyxis on every
unit.
43
Armstrong Institute for Patient Safety and Quality
Details in the differences…
Time from “STAT
Order Entry” to
“Pharm Verification”:
70% reduction
(p=0.005)
44
Armstrong Institute for Patient Safety and Quality
Details in the differences…
Time from “RN Med
Retrieval” to “Pt
Admin”:
77% reduction
(p=0.021)
45
Armstrong Institute for Patient Safety and Quality
Details in the differences…
Pyxis to Non-Pyxis Orders:
26% reduction (~21 mins)
46
Armstrong Institute for Patient Safety and Quality
Percent understanding patient care goals
Poor Communication Among Care
Providers
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Daily Goals
1
47
2
3
Residents
Nurses
4
5
6
Impact of Daily Goals on ICU Length of Stay
Daily Goals
2.5
Avg. LOS (days)
2
1.5
ICU LOS
1
0.5
ly
ug
us
t
Se
pt
O
ct
N
ov
D
ec
Ja
n
Fe
M b
ar
ch
A
pr
il
M
ay
A
Ju
Ju
ne
0
654 New Admissions = $7 Million Additional Revenue
ICU Discharge Medication Errors
• Goal: prevent medication errors in transfer orders
• Measure: Errors identified using discharge survey,
audit 15 patients per week
• Change: Medication reconciliation survey part of
routine discharge process
% of Patients Leaving
with Error
Discharge Survey Audit
100%
75%
50%
25%
0%
1
2
3
4
5
6
7
Week
8
9
10 11 12 13
Number of Medication Orders
Number of Medication Errors Prevented Per Week
Through the Medication Reconcillation Process
18
16
14
12
10
8
6
4
2
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16
Series1 14 9
3
0
5
7 16 7 7 14 13 8 11 3 12 5
Week
Inpatient Falls
Reviewed 15 months of fall data:
– 90% of falls occurred on night shift, within 1 hour of change of
shift, and on weekends.
Fall Reason
10
9
8
7
6
Pre-Implementation (15
months, n=23)
5
4
3
2
1
0
Bed alarms Bathroom BSC/Urinal
off
Walking
In/out of
chair
Restraints Fall prior to
removed
assess
52
Fall Reason
10
9
8
7
6
5
4
3
2
1
0
Pre-Implementatin (15
months, n=23)
Post-Implementatin (12
months, n=13)
53
Reducing Falls
Fall Rate
10
Intervention started
8
7
6
5
4
3
2
1
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
May-09
Apr-09
Mar-09
Feb-09
Jan-09
Dec-08
Nov-08
Oct-08
Sep-08
Aug-08
Jul-08
Jun-08
May-08
0
Apr-08
Falls per 1,000 Patient Days
9
NDNQI 10th Percentile
Fall Rate (Falls per 1000 patient days)
Baseline Fall Rate
2.92 falls/1000 pt-days
Post-Intervention Fall Rate
2.10 falls/1000 pt-days
Incidence Rate Ratio
0.72 (P value = 0.35)
Relative Risk Reduction
28%
54
% of respondents within an ICU reporting good safety climate
60
50
40
30
20
10
0
70
90
80
100
--WICU Time 3
--SICU
POST
--SICU
TimeCUSP
3
WICU POST CUSP
WICU PRE CUSP
SICU PRE CUSP
Safety Climate- Culture of Safety Survey
Culture of Safety- WICU/SICU
Questions
1. The senior leaders in my hospital listen to
me and
care about my concerns.
2. The physicians and nurse leaders in my area
listen
to me and care about my concerns.
3. My suggestions about safety would be acted
upon
if I expressed them to management.
4. Management/Leadership will never
compromise
safety concerns for productivity.
5. I am encouraged by my supervisors and
coworkers
to report any unsafe conditions I observe.
Relative %
Increase Before vs
After Program
22
30
30
22
32
Culture of Safety- WICU/SICU
Questions
Relative % Increase
Before vs After
Program
6.
I know the proper channels to report my safety
concerns.
30
7.
I am satisfied with availability of clinical leadership
(MD, RN, RPh).
44
8.
Leadership is driving us to be a safety-centered
institution.
35
9. I am aware that patient safety has become a
major area for improvement in my institution.
30
10. I believe that most adverse events occur as a
result of multiple system failures, and are not
attributable to one individual’s actions.
34
"Needs Improvement“ Statewide
Michigan CUSP ICU Results
100
90
•Less than 60% of respondents
reporting good safety climate =“needs
improvement”
•Statewide in 2004 84% needed
improvement, in 2006 41%
•Non-teaching and Faith-based
ICUs improved the most
•Safety Climate item that drives
improvement: “I am encouraged by
my colleagues to report any patient
safety concerns I may have”
80
84%
82%
70
60
50
47%
40
30
41%
20
10
0
Safety Climate
2004
Teamwork
Climate
2006
Teamwork Climate Across Michigan ICUs
% of respondents within an ICU reporting good teamwork climate
100
90
80
The strongest predictor of clinical excellence:
caregivers feel comfortable speaking up if they
perceive a problem with patient care
70
60
50
40
30
20
10
0
No BSI = 6 months or more w/ zero
No BSI 21%
No BSI 31%
No BSI 44%
Teamwork Climate &
Annual Nurse Turnover
100
90
% reporting positive teamwork climate
80
70
60
50
40
30
20
High Turnover 16.0%
Mid Turnover 10.8%
Low Turnover 7.9%
10
0
RN Teamwork Climate
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
Staff Physician Teamwork Climate
Michigan Keystone ICU
9
8
7
6
5
4
3
2
1
0
B
In as
te el
rv ine
en
tio
n
03
46
710 9
-1
13 2
-1
16 5
-1
19 8
-2
22 1
-2
25 4
-2
28 7
-3
31 0
-3
34 3
-3
6
CRBSI Rate
Median and Mean CRBSI Rate
N Engl J Med 2006;355:2725-32;
BMJ 2010;340:c309.
Time (months)
Armstrong Institute for Patient Safety and Quality
61
National On the CUSP: Stop BSI
n=1,821 teams from 1,081 hospitals
Armstrong Institute for Patient Safety and Quality
62
National On the CUSP: Stop BSI
Participating Adult ICUs cohort 1-5
n=1,292 ICUs
29% of ICUs in U.S.
Estimated:
294-613 deaths saved
$89.9 - $238.4 million excess costs averted
Armstrong Institute for Patient Safety and Quality
Michigan Keystone ICU
% Percent of ventilator days where patients
received all five therapies
Quarterly Composite Ventilator Bundle Adherence Over Time
100
80
60
40
20
0
Time (Months)
Infect Control Hosp Epidemiol. 2011 (in press)
Michigan Keystone ICU
Infect Control Hosp Epidemiol. 2011 (in press)
Leading Change
One of most common leadership mistakes is
expecting technical solutions to solve
adaptive problems….
Heifetz, Leadership Without Easy Answers
(Cambridge: Harvard University Press, 1994)
66
CUSP is a Continuous Journey
• CUSP is a marathon not a sprint
• Ask staff at least every six months how the next patient is
going to be harmed and invest the time and resources to
reduce this harm
• Learn from one defect per quarter and share lessons learned
• Implement teamwork tools that best meet
the teams needs
Acknowledgements
• Sallie Weaver, PhD
• Sean Berenholtz, MD, PhD
• Lori Paine, MS, RN
• Paula Kent, MSN, MBA, RN
• Peter Pronovost, MD, PhD
and
The Armstrong Institute for Patient Safety &
Quality
68
Armstrong Institute for Patient Safety and Quality
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•
•
•
•
•
•
•
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Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87.
•
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© JHU and JHHS, 2011
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