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On the CUSP: Stop CAUTI Cohort 8. Mapping the Journey: Hospital Unit Team Informational Webinar. January 30, 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
On the CUSP: Stop CAUTI Cohort 8

Mapping the Journey:

Hospital Unit Team

Informational Webinar

January 30, 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

Rose Rosales, BSN, MPA, RN, CCRN, CPHQ

East Orange General Hospital

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
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

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
  • 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

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

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
unit team success story east orange general hospital
Unit Team Success Story: East Orange General Hospital

Rosemarie D. Rosales


Administrative Director of Nursing Operations

East Orange General Hospital

East Orange, NJ

east orange general hospital1
East Orange General Hospital
  • This hospital is a 212-bed community hospital located in Essex County in Central New Jersey.
  • Primary Service Areas are cities of East Orange and Orange.
  • The unit chosen for the project is a 29 bed medical-surgical, renal and oncology unit.
project team members
Project Team Members

President & CEO – Kevin J. Slavin, FACHE

Hospital Executive Champion

  • Mary Anne Marra, RN, MSN, NEA-BC - VP of Patient Care Services and CNO

Physician Champion

  • Dr. Elizabeth Mammen- Prasad - Physician Chair of IC Committee
  • Dr. Samya Shafi – ID Section Chair

Project Team Leader

  • Rosemarie D. Rosales, BSN, MPA, RN, CCRN,CPHQ

Adm. Director of Nursing Operations

project team members1
Project Team Members

Infection Preventionist or Epidemiologist

  • Juliet Brown, CIC- Manager of Infection Control

Process Data Collector

  • Elizabeth Entzminger, LPN -IC Surveillance Nurse

Data Entry and Report User

  • Aldyth Stanford, RN – IC Coordinator
  • Charina Silvera, RN – Clinical Coordinator


ED Nurse Manager – Benson Kahiu, RN, BSN

PI Coordinator - Sharon Lawson-Davis , BSN, RN

why we joined the national on the cusp collaborative
Why we Joined the NationalOn the CUSP Collaborative

CAUTI is one of the never events as identified by both CMS and TJC.

Our institution is committed to succeed in our quest for our project initiative “LEANING to ZERO”.

our journey
  • Join the NJHA state calls
  • Chose unit – the most CAUTI in 2011
  • Educate the Leaders of the designated unit – 2 West on the CAUTI initiatives
  • Presented the project to the Infection Control Committee
  • Collaboration of the Infection Prevention Team, ED Team and 2 West Leaders
cauti initiatives
CAUTI – Initiatives
  • ED surveillance of patients with Foley coming from other facilities.
  • Foley change and doing C&S if criteria met for Foley maintenance by ED staff.
  • IC surveillance nurse along with clinical coordinator/designee doing daily Foley rounds
  • Foley Policy & Procedure revised to include change of Foley after two weeks and to do urine C&S as ordered by MD
  • Foley Bag with Orange Sticker to indicate Foley insertion date, reason for Foley, date of Foley change if applicable
cauti goals
  • Establish criteria for having a Foley
  • Decrease CAUTI by 50% on the designated unit from 2011 but aim for ZERO as CAUTI is one of the NEVER Events.
  • Obtain support of Medical Staff Leadership with approval of the Automatic
  • Discontinuation of Foley if it does not meet criteria
criteria established for foley insertion and maintenance
Criteria Established For Foley Insertion and Maintenance
  • Strict Intake & Output
  • Stage 3 or 4 sacral pressure ulcers
  • Bladder outlet obstruction
  • After urological surgeries or other surgeries requiring Foley
  • End of Life Care
  • Foley maintained after 24-48 hours of surgery requiring MD notation or orders
  • Patients assessed for Foley on admission – Foley changed and urine C&S obtained

Hand off communication or Incorporate into change of shift report i.e. continued need / discontinue use of Foley catheter

  • Educate all staff on the CAUTI initiatives and the CAUTI Bundle
  • Include Foley Care, CAUTI Initiatives and CAUTI bundle in Nursing Competencies
  • Placing an Orange Sticker on the Foley bag with the date of insertion as a reminder
  • Foley catheter change if Foley is maintained after two weeks
barriers to success for the initial rollout
Barriers to success for the initial rollout:
  • Nurses perception of the need for foley vs. using the criteria for foley insertion.
  • Patients were not regularly assessed for the need for the device.
  • Foleys were not consistently changed in the ER if they came in with foleys.
  • UA and Urine C & S were not routinely part of the admission labs for those with foleys.
  • Staff not familiar with the Indications for foley and the automatic discontinuation
engagement is essential to project success
Engagementis Essential to Project Success
  • Supportive Hospital Leadership
  • Supportive Quality Board
  • Supportive unit team members
how we engaged others
How We Engaged Others
  • Nursing/ unit team engagement
    • Unit team leader taking the lead in ensuring staff involvement
    • Clinical coordinator/designee ensuring data collection and data input
    • Collaboration of unit leaders, staff and the infection prevention team(daily rounding)
    • Buy-in of team (improve patient care and quality)
  • Interdisciplinary support of project
    • 7 day coverage/ support of the infection prevention team (daily rounding)
    • Buy in from the ED Medical and Nursing staff
    • Accountability among all unit staff
    • Science of safety video shown in orientation
    • CUSP training a part of unit orientation for all staff
    • Regular competency exams for unit nurses
    • Roll out of the project to all units
our project successes
Our Project Successes
  • ZERO CAUTI’s from June, 2011 to December, 2013
  • Won the top CAUTI Award for Cohort 3 from NJHA, 2013
  • CAUTI Poster won third place at the University of Texas Health Science Center, July 2013
lessons learned
Lessons Learned
  • Buy-in from all levels is essential to project success
  • Regular communication and support among staff are key to success
  • Project visibility supports sustainability
    • Monthly reporting to Infection Prevention Committee
    • Quarterly reporting PI & Patient safety Committee and Board of Quality
    • Visible executive team members, project sponsors and champions
    • Celebrate successes and wins at every opportunity
    • Posting project achievements
cauti collaborative cohort 3
CAUTI Collaborative Cohort 3


Thank you for allowing East Orange General Hospital to share our successes

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
your feedback is important
Your Feedback is Important!


key takeaways
“Key Takeaways”

Patient Safety is a TEAM SPORT

The CUSP/CAUTI program is here to support YOU in building effective teams and reducing harm

Have questions? Visit the project website here for more information.

how to join
How to Join

If you are interested in joining either the

ED or Inpatient CAUTI initiative

Contact your State Lead to sign-up today!

With questions contact Neel Pathak, npathak@aha.org

for more information about on the cusp stop cauti project
For More Information about On the CUSP: Stop CAUTI project


Please visit the project website: http://www.onthecuspstophai.org/on-the-cuspstop-cauti/

With questions contact Neel Pathak, npathak@aha.org


For future questions, contact:

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):