On the cusp stop cauti cohort 8
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On the CUSP: Stop CAUTI Cohort 8 PowerPoint PPT Presentation

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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

Mapping the Journey:

Hospital Unit Team

Informational Webinar

January 27, 2014

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

  • 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

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

  • 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

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

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

  • 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

Registered Unit Type

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 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?

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

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

    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?

    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?


    • Each registered unit will have protected access

    • MHA will provide webinar training and technical support for:

      • entering your data

      • running your own reports


    • 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

    • 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)

    • 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

    • 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?

    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?

    • 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?

    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?

    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?

    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?

    • 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 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)

    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?

    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


    • 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

    • 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?

    • 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

    • 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

    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

    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

    • 611 bed – Major teaching hospital

    • Unit 450 – 16 bed ICU

      • Neuro/Neurosurgical

      • Medical

      • Pulmonary

      • Vascular surgery

      • General surgery

    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

    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

    Ventilated Patient Guidelines


    Unit Success

    Reduction in Utilization Rates

    Reduction in CAUTI rates

    CUSP start

    63% Reduction in CAUTIs in 9 months!

    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

      [email protected]

    • Jenny Tuttle RN, MSNEd, CNRN - ACCU Manager

      (520) 903-4090

      [email protected]

    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

    Comprehensive Unit Safety Program AND CAUTI prevention:


    Emergency Department Improvement Intervention:


    Agency for Healthcare Research & Quality (AHRQ):


    Your Feedback is Important!



    For future questions, contact:

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