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On the CUSP: Stop CAUTI Cohort 8. Mapping the Journey: Hospital Unit Team Informational Webinar. January 27, 2014. Today’s Presenters. Tina Adams, RN Clinical Content Lead HRET Barbara Meyer Lucas, MD, MHSA Project Consultant Michigan Health & Hospital Association

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On the CUSP: Stop CAUTI Cohort 8

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On the cusp stop cauti cohort 8

On the CUSP: Stop CAUTI Cohort 8

Mapping the Journey:

Hospital Unit Team

Informational Webinar

January 27, 2014

Today s presenters

Today’s Presenters

Tina Adams, RN

Clinical Content Lead


Barbara Meyer Lucas, MD, MHSA

Project Consultant

Michigan Health & Hospital Association

Keystone Center for Patient Safety and Quality

Jenny Tuttle RN, MSNEd

Tucson Medical Center

Adult Critical Care Unit



Objectives for today

Objectives for today

  • Understand the inpatient unit catheter associated urinary tract infection (CAUTI) prevention program including the comprehensive unit safety program (CUSP)

  • Understand the collection and use of outcome and process measures data

  • Understand the role of the unit’s Team Leader

National project goals

National Project Goals

The Project Goals for CAUTI are to:

  • reduce mean CAUTI rates in participating clinical units by 25 percent; and

  • improve safety culture as evidenced by improved teamwork and communication by employing CUSP methodology.

Resources cauti website

Resources, CAUTI Website

  • CAUTI prevention:http://www.onthecuspstophai.org/on-the-cuspstop-cauti/

  • CUSP patient safety culture modules: http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/

  • Emergency Department Improvement Intervention:http://www.onthecuspstophai.org/on-the-cuspstop-cauti/toolkits-and-resources/emergency-department-improvement-intervention/

National project team

National Project Team

HRET – Health Research & Educational Trust

MHA – Michigan Health and Hospitals Association, Keystone Patient Safety Center

U of M – University of Michigan

St John – St. John Hospital and Medical Center

Extended Faculty Network:

APIC – Association for Professionals in Infection Control and Epidemiology, Inc.

SHEA – Society for Healthcare Epidemiology of America

SHM – Society of Hospital Medicine 

ENA – Emergency Nurses Association

All biographies located here: http://www.onthecuspstophai.org/about-us/key-personnel/

National project partnerships dissemination model

National Project Partnerships & Dissemination Model

CAUTI National Project Team


State Hospital Associations, Partners & Coalitions

Extended Faculty Network

State Leads, Quality Improvement Organization, Hospital Engagement Network,- Coaching/CUSP/

Recruitment/Project Liaison

National & Regional CAUTI Faculty APIC, SHEA, SHM, ENA

Coaching/Recruitment/ Endorsement


Learning the project language

Learning the Project Language

  • Cohort

  • “State” or “Regional” Lead

  • Unit CUSP Team and Team Leader

  • Unit Survey Coordinator

  • Outcome Measures

  • Process Measures

First 7 cohorts 42 sates 962 hospitals

First 7 Cohorts, 42 sates, ~962 Hospitals

Registered unit type

Registered Unit Type

Key components of intervention

Key Components of Intervention

What will you be doing in this project?

Technical (Clinical)

  • Catheter Insertion

  • Appropriate vs. Inappropriate Indications

  • Process to Evaluate Urinary Catheter Need

    Socio-Adaptive (Cultural)

  • Teamwork and communication improvements surrounding the unit’s patient safety culture

Key components of intervention1

Key Components of Intervention

2) Socio-Adaptive (Cultural) continued

  • Comprehensive Unit-based Safety Program (CUSP)

    • Unit CUSP Team formed

    • Requires a Team Leader

    • Meets regularly (weekly or at least monthly)

    • Composed of engaged frontlinestaff who take ownership of patient safety (e.g. bedside nursing staff)

    • Includes staff members who have different levels of experience

    • CUSP Team includes nurse manager, physician, senior executive

    • CUSP Team may include infection control/prevention, central supply staff member, PT/OT staff, discharge planner

    • Tailored to include members based on clinical intervention

What will be provided

What will be provided?

Educational events: Teleconferences, webinars, in-person meetings (with video conferencing)

  • For example: 6 Onboarding Calls, Monthly Content Calls, and 3 Learning Sessions

    Materials: Implementation guide with tools (guidelines, posters, forms, educational materials)

    Coaching: National and regional supported calls

    Data: On-line secure collection and reporting

    Site visits: NPT determined

Cohort 8 timeline

Cohort 8 Timeline

Next steps cohort 8

Next Steps – Cohort 8

  • Hospital Unit Informational Webinars – January 27 and 30, 2014; same content offered twice, recording available online

  • Recruitment of hospital units: January – March, 2014

  • Team registrationdeadline: April 1, 2014

  • Learning Session (LS) #1: March 17 – 31 at the state/sponsor level

    • LS #1 NPT Office Hours – April 2, 2014 from 3-4pm ET

  • Onboarding Webinar Series (6) – Begin early April through min June

  • On the cusp stop cauti

    On the CUSP: Stop CAUTI

    CAUTI Project Data:

    An Overview for Unit Teams

    Barbara Meyer Lucas, MD, MHSA, CPPS

    Michigan Health and Hospital Association (MHA)

    Keystone Center for Patient Safety and Quality

    Data collection why is it crucial to the project

    DATA COLLECTION: Why is it crucial to the project?

    Project’s data elements will help you:

    • Stay on course to achieve BOTH project goals

      • reduce your unit CAUTI rate by 25%

      • improve your unit’s culture of safety

    • Track your use of recommended technical work and CUSP interventions

    • Identify barriers to your progress

    Data collection where is it housed

    DATA COLLECTION: Where is it housed?


    • Each registered unit will have protected access

    • MHA will provide webinar training and technical support for:

      • entering your data

      • running your own reports

    Cauti project data elements


    • Background/Culture Data:

      • Readiness Assessment

      • HSOPS: Baseline and Follow-up

    • Ongoing Data Submission:

      • Outcome data

      • Process Data (optional)

      • Team Checkup Tool

    Background culture data readiness assessment

    BACKGROUND/CULTURE DATA: Readiness Assessment

    • PURPOSE: Tells us about your unit:

      • Size, type, patient demographics, etc.


      • Completed ONCE at start of project

      • Done via Survey Monkey by ONE person per unit

    Background culture data hospital survey on patient safety hsops

    BACKGROUND/CULTURE DATA: Hospital Survey on Patient Safety (HSOPS)

    • PURPOSE: Standardized measure of safety culture for individual patient care unit (NOT hospital-wide)


      • Done twice: at the start of the project, and after the project intervention

      • Given to all unit staff

    Ongoing data collection outcome and process data

    ONGOING DATA COLLECTION:Outcome and Process Data

    • OUTCOME DATA: What impact have we made on our 2 project goals:

      • reducing the CAUTI rate by 25% and

      • improving our unit’s culture of safety

    • PROCESS DATA (optional): Are we changing our daily work activities to reduce the risk of infection and make care safer, via BOTH:

      • technical work re: catheters

      • CUSP work (unit culture change)

    Cauti outcome data what do we collect

    CAUTI OUTCOME DATA: What Do We Collect?

    For the entire month (not just M-F) each enrolled unit must collect and submit:

    • Total # of patient days for that unit

    • Total # of indwelling urinary catheter days for that unit

    • Total # of CAUTI’s for that month

      Result: CAUTI Rates and Catheter Prevalence

    Cauti outcome data what infrastructure do teams need

    CAUTI OUTCOME DATA: What Infrastructure Do Teams Need?

    • Someone to collect the data

      • Should be knowledgeable about NHSN criteria

        • Should resolve any “questionable CAUTI” issues before entering data

        • Good resource: ICP

    • Someone to enter the data

      • Either into Care Counts or NHSN (if state level data will be imported from NHSN into Care Counts)

    Cauti outcome data when is it due

    CAUTI OUTCOME DATA: When is it due?

    Starts in MAY, with Three Phases

    • BASELINE (Monthly submission)

      May, June, July 2014

    • IMPLEMENTATION (Monthly submission)

      August and September 2014

    • SUSTAINABILITY: (1 month per quarter)

      Dec 2014; March and June 2015

    Process data optional submission what do we collect

    PROCESS DATA (optional submission): What Do We Collect?

    DAILY, following the submission schedule:

    • # of patients on the unit that day

    • # of catheterized patients on the unit that day

    • Main reason why patient has a catheter TODAY

    • Where the catheter was inserted (on the floor, off the floor, unknown)

      Result: Catheter Appropriateness Information

    Process data when is it due

    PROCESS DATA: When is it due?

    Starts in JULY, with Three Phases

    Submit to Care Counts database on specific scheduled dates:

    • July 2014:M-F for 3 weeks

    • August and September 2014: on 16 scheduled days

    • After that: M-F for one week per quarter

      (December 2014; March and June 2015)

      Note: Process data submission is optional

    Cauti process data what infrastructure do teams need

    CAUTI PROCESS DATA: What Infrastructure Do Teams Need?

    • Need a rounding process (not record review)

      • IDEAL: piggyback on existing unit rounds

      • We provide a model audit tool

    • Need a designated point person to:

      • Record data

      • Contact physicians for catheter removal order

      • Submit data to Care Counts

    Cauti process data what infrastructure do teams need1

    CAUTI PROCESS DATA: What Infrastructure Do Teams Need?


      • Rounding for catheter appropriateness goes on daily, regardless of whether you choose to submit that data.

        Remember: This rounding process IS the intervention!!!

    Ongoing data collection quarterly team checkup tool tct

    ONGOING DATA COLLECTION:Quarterly Team Checkup Tool (TCT)

    What it assesses:

    • Implementation of CUSP and CAUTI reduction activities

    • Team functioning

    • Barriers to project progress

      Submit to Care Counts database at MHA

    Team checkup tool when is it due

    TEAM CHECKUP TOOL: When Is it Due?

    Starts in AUGUST 2014

    • Team submits their consensus response quarterly

    • Reflects the team’s work for the previous 3 months

    • Schedule: due quarterly

      AUGUST 2014 (reflects work of May-July), then: Nov 2014; Feb and May 2015

    Take home message


    • Data Collection Process:

      • Is front-end loaded, but manageable

      • You will have support from the national team

    • Remember:

      Data drives change!

      Daily rounding for catheter presence and appropriateness IS the intervention!

    Unit cusp team s goal

    Unit CUSP Team’s Goal

    • Develop and or expand capacity at the hospital unit level to support improvement by:

      • CUSP content expertise

      • CAUTI prevention expertise

        Reduce CAUTI and Improve Safety

    Where do we start

    Where do we start?

    • Select a CUSP-CAUTI Program Team Leader

    • Characteristics:

      • Seen as an leader by bedside staff

      • Go-to person to get questions answered

      • Able to influence others

    Team leader tasks

    Team Leader Tasks

    • Review Implementation Manual

    • Attend all program educational opportunities

    • Develop a CUSP-CAUTI team (bedside caregivers)

    • Schedule regular CUSP-CAUTI Team meetings

    • Educate CUSP-CAUTI Team

    • Involve all Team members in Team tasks

    • Provide feedback to Team members

    • Communicate with Senior Executive

    • Assure data/survey results submitted

    Unit team tasks

    Unit Team Tasks

    Attend and participate in CUSP Team meetings

    Provide bedside staff member’s perspective

    Implement CUSP-CAUTI program by sharing responsibility for the Team’s work

    • Participate in design of processes to prevent CAUTI and to employ CUSP interventions on your unit

    • Educate staff, physicians, patients and families

    • Champion effort, provide feedback to bedside staff

    • Data collection and submission

    • Celebrate successes along the way

    Cauti unit team a success story

    CAUTI Unit Team: A Success Story

    Unit 450 CAUTI Team:

    Melanie Bunger RN - NightsAunneShepler RN - Nights

    Julie Davis RN- DaysPat Smothers, PCT - Days

    Stephanie Donovan RN, MSNEdJenny Tuttle RN, MSNEd

    Lisa Hymson, Infection ControlLisa Vasquez RN - Days

    Nina Mazzola, Manager Infection Control

    Hospital information

    Hospital Information

    • 611 bed – Major teaching hospital

    • Unit 450 – 16 bed ICU

      • Neuro/Neurosurgical

      • Medical

      • Pulmonary

      • Vascular surgery

      • General surgery

    Why we joined the national on the cusp collaborative

    Why we Joined the NationalOn the CUSP Collaborative

    • 2012 CAUTI rate data for the unit reflected a need for an improvement process.

    • Worst CAUTI rate in the house.

    • CUSP program provided us a venue of support and structure – Cohort #5

    Our journey

    Our Journey

    Audit Process

    Customizing tool to evaluate for deficits

    Identifying barriers – Cracking the ICU mentality

    Case Reviews - Team

    Isolating root cause

    Review processes/practices

    Identifying vented patient populations - guideline

    Collaboration with other Departments

    Emergency Room

    Operating Room



    Providing the staff the tools/supplies

    Assessing supplies currently available

    Product trials

    Audit tool

    Audit Tool

    Ventilated patient guidelines

    Ventilated Patient Guidelines


    Unit success

    Unit Success

    Reduction in Utilization Rates

    Reduction in CAUTI rates

    CUSP start

    63% Reduction in CAUTIs in 9 months!

    Lessons learned

    Lessons Learned

    Constant conversations

    A simple thing as WHO is doing the audit can make a difference

    Continual evaluation of audit tool/process

    Improved compliance when staff given the tools to change

    Physician buy in

    Still work to be done



    • Nina Mazzola - Infection Control Manager

      (520) 324-2536


    • Jenny Tuttle RN, MSNEd, CNRN - ACCU Manager

      (520) 903-4090


    Did we meet today s call objectives

    Did We Meet Today’s Call Objectives?

    • Understand the inpatient unit catheter associated urinary tract infection (CAUTI) prevention program including the comprehensive unit safety program (CUSP)

    • Understand the collection and use of outcome and process measures data

    • Understand the role of the unit’s Team Leader

    Resources on cusp cauti websites

    Resources on CUSP-CAUTI Websites

    Comprehensive Unit Safety Program AND CAUTI prevention:


    Emergency Department Improvement Intervention:


    Agency for Healthcare Research & Quality (AHRQ):


    Your feedback is important

    Your Feedback is Important!




    For future questions, contact:

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