Transcript Presentation Title Line 1 Presentation Title Line 2

Comprehensive
Unit-based
Safety Program
(CUSP)
Teré Dickson, MD, MPH
HAI Webinar
April 9, 2012
CMS
 Leads a national healthcare quality improvement program,
implemented locally by an independent network of QIOs in
each state and territory.
IPRO
 The federally funded Medicare Quality Improvement
Organization (QIO) for New York State, under contract with
the Centers for Medicare & Medicaid Services (CMS).
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The QIO Program
 Largest federal program dedicated to improving health
quality at the local level,
 Trustworthy partners for the continual improvement of
healthcare for all Americans,
 Focuses on three broad aims:
 Better patient care,
 Better population health,
 Lower healthcare costs through improvement.
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As the QIO for New York State, IPRO works to achieve
the goals of the national QIO program by
 Convening communities of providers, practitioners and
patients across the state to:
 Share knowledge,
 Spread best practices,
 Achieve rapid, wide-scale improvements in patient
care.
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The QIO Program supports patients by:
 Providing information to help you better manage your
own healthcare,
 Reviewing quality of care complaints,
 Working with local healthcare providers to make
healthcare safer and “patient-centered,”
 Listening to you and learning from your experiences,
 Helping to remove roadblocks between you and better
healthcare.
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The QIO Program supports providers by:
 Managing and sharing evidence-based best practices,
knowledge and tools for improving health quality, efficiency
and value.
 Serving as a change agent for rapid, widespread and
significant improvements that contribute to broader national
healthcare goals.
 Facilitating collaborative learning and action that results in
better, more patient-centered care.
 Encouraging beneficiaries to take a more active role in their
own healthcare.
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QIO Program Priorities 2011-2014
 Beneficiary- and Family-Centered Care
 Improving Individual Patient Care by Reducing
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Healthcare-Associated Infections in Hospitals
Healthcare-Acquired Conditions in Nursing Homes
Adverse Drug Event
and through Quality Reporting
 Integrating Care for Populations and Communities
 Improving Health for Populations and Communities
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Today’s Webinar:
CUSP Town Hall Meeting
A town hall meeting is an informal public meeting which
gives the members of a community an opportunity to
get together to discuss emerging issues and to voice
concerns and preferences for their community.
- www.wisegeek.com
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Interact with us!
 Operator assisted call
 Chat box
 To the group
 To the moderator
 When you respond or comment, please say your name and
hospital.
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Special Guests –
St. John’s Episcopal Hospital
St. John’s Episcopal Hospital is the only full service
community hospital serving the entire Rockaway and
the Five Towns communities providing general adult
medical surgical services, pediatrics, obstetrics and
psychiatric services.
 Initiated CUSP in January 2010
 Gail Johnson
 Nancy Traver
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Poll Question 1
My hospital has started using CUSP to address
CLABSIs and CAUTIs.
 Yes
 No
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Poll Question 2
My hospital has considered using CUSP, but either
decided against it or doesn’t know how to get started.
 Yes
 No
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Poll Question 3
My hospital has an alternative to CUSP in place, such
as the use of brainstorming teams, multidisciplinary
patient safety rounds with hospital administration,
feedback to unit staff on infection rates and targets,
educational sessions for unit staff, and/or application of
root cause analysis to investigate infections.
 Yes
 No
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Principles of CUSP
 Understand system determines performance and results.
 Use strategies to improve system performance.
 Apply strategies to both technical work and team work.
 Recognize teams make wise decisions with diverse and
independent input.
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Five Steps of CUSP
1.
2.
3.
4.
5.
Educate staff on the science of safety
Identify defects
Assign executive to adopt unit
Learn from one defect per quarter
Implement teamwork tools
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The 4E’s to CUSP Success
 Engage
 Storytelling, Press releases, Share data
 Educate staff on evidence
 Execute
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Standardize
Create independent checks
Empower nursing
Learn from mistakes
 Evaluate
 Performance and progress feedback
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Keep It Simple
CUSP
 Learn from 1 defect per desired time period
 Collaboration
 Consolidation
 Sustainability
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CUSP In-depth
On The CUSP: Stop HAI
http://www.onthecuspstophai.org/
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The St. John’s Episcopal Hospital CUSP
Experience
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Choosing CUSP
Driving Forces
 High CLABSI Rate
 MICU: 2.6/1000 device days in 2010 with a national mean of 1.9
 Hospital Administrator - Sharon Behar, VP for Regulatory
Affairs
 HANYS and national On the CUSP initiative
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Pre-CUSP Activities
 Web Conferences
 Team Formation
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Administrative Champion
Infection Control Committee Chairman
Physician Champion
Nursing Champion (VP of Patient Care Services)
Infection Preventionist
 Data Collection
 AHRQ Hospital Survey on Patient Safety
 Trained staff on Science of Safety
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CUSP Processes for CLABSI Prevention
 Removal of the defects that lead to central line related
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bacteremia
Understanding the complexity involved to creating a plan
to reduce errors
Putting all equipment needed for insertion in one place
and/or pkg
Residents must notify nurse who will assist with insertion
Insertion checklist to empower nurses to document
deviations
Observing Rounds
AM and PM Briefing
Daily Goals Checklist
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CUSP Intervention - Peer Review
 Developed the peer
review form to assess the
compliance with all
strategies and bundles.
 The night shift monitors
the day shift on care for
patients with lines and
vice versa.
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CUSP Results
MICU had a rate of 2.6/1000 device days in 2010 with a
national mean of 1.9
 2011: the rate had dropped to 1.5 below the national mean
of 1.6
Feedback to Staff
 CUSP Boards where infection rates were posted monthly
 Fun Competition
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CUSP Sustainability and Expansion
After about 6 months, noticed modest gains in monthly
rate reduction
 Decided to host more CUSP trainings with video about
Josey King
At 9 months – CUSP went housewide! (Med Surg and
Pulmonary floors)
 Recruited different physician champions and unit/floor
champions with same administrative champion
 Champions brought others on board with roll-out and were
instrumental in CUSP success
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Townhall Discussion
 Data resources used
 Education tactics – Science of Safety and CUSP
directed initiatives
 Engagement tactics – Executive and front line staff
 Team member selection and team building
 Scheduling concerns – consolidate with other
meetings vs separate timing
 Investigations of defects
 Feedback methods
 Sustainability
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Townhall Discussion
What is your hospital doing as an
alternative to CUSP?
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Feedback on CUSP Trainings and Resources
 Fall LAN Meeting
 AHRQ/HRET National Webinar on CUSP
 http://hai.ipro.org
 Quarterly Newsletters – CUSP Corner
 Today’s Webinar/Townhall
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This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM7.1-12-04
For more information
Teré Dickson, MD, MPH
Medical Officer
(516) 209-5324
[email protected]
IPRO CORPORATE HEADQUARTERS
1979 Marcus Avenue
Lake Success, NY 11042-1002
IPRO REGIONAL OFFICE
20 Corporate Woods Boulevard
Albany, NY 12211-2370
www.ipro.org
Template 1/13/2012