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The Comprehensive Unit-based Safety Program (CUSP):

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The Comprehensive Unit-based Safety Program (CUSP): An intervention to learn form mistakes and improve safety culture www.safercare.net – PowerPoint PPT presentation

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Title: The Comprehensive Unit-based Safety Program (CUSP):


1
The Comprehensive Unit-based Safety Program
(CUSP)
An intervention to learn form mistakes and
improve safety culture www.safercare.net
2
Learning Objectives
  • To understand the steps in CUSP
  • To learn how to investigate a defect
  • To understand some teamwork tools such as daily
    goals, AM briefing, Shadowing

3
Safety Score CardKeystone ICU Safety Dashboard
  2004 2006
How often did we harm (BSI) 2.8/1000 0
How often do we do what we should 66 95
How often did we learn from mistakes 100s 100s
Have we created a safe culture  
Needs improvement in Safety climate 84 43
Teamwork climate 82 42
CUSP is intervention to improve these
4
Pre CUSP Work
  • Create an ICU team
  • Nurse, physician administrator, others
  • Assign a team leader
  • Measure Culture in the ICU(discuss with hospital
    association leader)
  • Work with hospital quality leader to have a
    senior executive assigned to ICU team

5
71 Teamwork Climate 2008
67 Teamwork Climate 2007
64 Teamwork Climate 2006
62 Teamwork Climate 2005
6
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7
Comprehensive Unit-based Safety Program (CUSP)
An Intervention to Learn from Mistakes and
Improve Safety Culture
  • Educate staff on science of safety
    http//www.safercare.net
  • Identify defects
  • Assign executive to adopt unit
  • Learn from one defect per quarter
  • Implement teamwork tools

Pronovost J, Patient Safety, 2005

8
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 team
    work
  • Recognize teams make wise decisions with diverse
    and independent input

9
Identify Defects
  • Review error reports, liability claims, sentinel
    eventsor M and M conference
  • Ask staff how will the next patient be harmed

10
Prioritize Defects
  • List all defects
  • Discuss with staff what are the three greatest
    risks

11
Executive Partnership
  • Executive should become a member of ICU team
  • Executive should meet monthly with ICU team
  • Executive should review defects, ensure ICU team
    has resources to reduce risks, and how team
    accountable for improving risks and central line
    associated blood steam infection

12
Learning from Mistakes
  • What happened?
  • Why did it happen (system lenses)
  • What could you do to reduce risk
  • How to you know risk was reduced
  • Create policy / process / procedure
  • Ensure staff know policy
  • Evaluate if policy is used correctly

Pronovost 2005 JCJQI
13
To Identify most important contributing factors
  • Rate Each contributing factor
  • importance of the problem and contributing
    factors in causing the accident
  • importance of the problem and contributing
    factors in future accidents

14
To identify most effective interventions
  • Rate Each Intervention
  • How well the intervention solves the problem or
    mitigates the contributing factors for the
    accident
  • Rates the team belief that the intervention will
    be implemented and executed as intended

15
To 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

16
Teamwork Tools
  • Call list
  • Daily Goals
  • AM briefing
  • Shadowing
  • Culture check up

Pronovost JCC, JCJQI
17
Call List
  • Ensure your ICU has a process to identify what
    physician to page or call for each patient
  • Make sure call list is easily accessible and
    updated

18
AM briefing
  • Have a morning meeting with charge nurse and ICU
    attending
  • 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

19
Shadowing
  • Follow another type of clinician doing their job
    for between 2 to 4 hours
  • Have that person discuss with staff what they
    will do differently now they walked in another
    shoes

20
Culture Check-UP
  • Pick you lowest three items on your culture score
  • Ask staff if this reflects their reality
  • Ask what it would be like if you scored 100 on
    this (eg what behaviors would people do)
  • Discuss what you can do to put those behaviors in
    place
  • Make a plan

21
CUSP is a Continuous Journey
  • Add science of safety education to orientation
  • Learn from one defect per month, share or post
    lessons (answers to the 4 questions) with others
  • Implement teamwork tools that best meet the ICU
    teams needs
  • Details of CUSP are in the manual of operations

22






Statistically Significant
23
4. I Would Feel Safe Being Treated Here As A
Patient.
 
of respondents within an ICU that agree
24
3. Nurse Input Is Well Received In This ICU.
 
of respondents within an ICU that agree
25
"Needs Improvement Statewide Michigan CUSP ICU
Results
  • 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

 
26
Michigan ICU Safety ClimateScore Distributions
27
Focus and Execute
28
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29
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, Lipsett PA,
    Simmonds T, Haraden C. 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, Sexton JB,
    Pronovost PJ. A morning briefing Setting the
    stage for a clinically and operationally good
    day. Jt Comm J Qual and Saf. 2005
    31(8)476-479.
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