Transcript www.whaqualitycenter.org

Comprehensive
Unit Based
Safety
Program

A webinar series for QI Managers, Nurse Leaders and others
supporting healthcare improvement
in Wisconsin’s hospitals

July 2012
A Four Part Series
Part I – July 10th
The Science of Safety and forming the CUSP team
Part II – August 7th
The Staff Safety Assessment & Safety Huddles
Part III – September 4th
Identifying Defects
Part 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 Series
Levels 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 CUSP
The 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
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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
This is a
Standardized
approach
NOT just for
BSI.
STOP CAUTI
STOP FALLS
STOP VAP
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• 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
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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.”
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-- Richard Enrico,
CEO PepsiCo, 1995
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 Culture
Safety 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:
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!)
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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”
(But much more difficult to “fix”)
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National Data Trends
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Strengths and Areas for Improvement
Strengths for Most Hospitals
Pct.
Needed Improvement for Most
Positive 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
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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:
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Team Leader/Safety
Physician
Executive Champion
Staff Nurse (ideally one from each shift)
• Other potential team members:
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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 from
a complex interplay of multiple factors.
Only rarely are they due to the carelessness or
misconduct of single individuals
Lucien L. Leape, MD
Harvard School of Public Health
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How Can These Errors Happen?
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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
Why Mistakes Happen?
Process Factors
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Variable input (diff pts)
Inconsistency/variation
Complexity
Too many/complicated
steps
• Human intervention
• Tight time constraints
• Hierarchical culture
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People Factors
• Fatigue
• Inattention/distraction
• Unfamiliar situations/new
problem
• Using past solutions
• Equipment design flaws
• Communications errors
• Mislabeling/inadequate
instructions
System Failure Leading to This Error
A case study:
Communication between
resident and nurse
Inadequate training
and supervision
Catheter pulled with
Patient sitting
Patient suffers
Venous air embolism
Lack of protocol
For catheter removal
8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.
9. Reason J, Hobbs A., 2000.
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System Factors Impact Safety
Institutional
Hospital
Departmental Factors
Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics
Adapted from Vincent BMJ
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How Can We Improve?
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
Caregivers are not to blame
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Principles of Safe Design
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Standardize
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Eliminate steps if possible
Create independent checks
Learn when things go wrong
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What happened?
Why?
What did you do to reduce the risk?
How do you know it worked?
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What Happens When We Focus
on Patient Safety?
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% of respondents within an ICU reporting good teamwork climate
Teamwork
Climate Across Michigan ICUs
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90
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The strongest predictor of clinical excellence:
caregivers feel comfortable speaking up if they
perceive a problem with patient care
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No BSI = 5 months or more w/ zero
No BSI 21%
No BSI 31%
No BSI 44%
0
Health Services Research, 2006;41(4 Part II):1599.
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The Science of Safety Resources
Webinar 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 Homework
In the next 30 days:
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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 Up
Mid-month Check Up
Via a web survey Questionnaire sent out on July 27th
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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
AHRQ Safety Survey Tools:
http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm
CUSP Resources:
http://65.23.152.3/stop-bsi/manuals-and-toolkits/
http://www.nejm.org/doi/full/10.1056/NEJMcpc1007085
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Thank You
Questions?
Jill Hanson & Stephanie Sobczak
Wisconsin Hospital Association
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