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CLABSI Supplemental Call Series. The Organizational Embrace of CUSP to Improve Patient Safety. March 20, 2012. Objectives.

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The organizational embrace of cusp to improve patient safety

CLABSI Supplemental Call Series

The Organizational Embrace of CUSP to Improve Patient Safety

March 20, 2012


  • To relate an organization’s approach to implementing CUSP in multiple areas of the hospital to reduce harm beyond CLABSI and CAUTI and to improve the overall culture of safety

  • To discuss the mechanics at the hospital level of standing up and supporting CUSP teams


Holy Cross Hospital Silver Spring, MarylandYancy Phillips, MD, MACP, Vice President Quality and

Care ManagementSean Maxwell, Lead Angiography TechnicianUpper Chesapeake Health

Havre de Grace and Bel Air, MarylandJim Hursey, MBA, Sr. VP, COOJudi Webster, RN, BSN, PI Patient Safety Coordinator

Holy Cross Hospital

CUSP Beyond the ICUHoly Cross HospitalSilver Spring, MarylandYancy Phillips, MD, MACP, Vice President Quality and Care ManagementSean Maxwell, Lead Angiography Technician


  • A little about us

  • CUSP teams as the lever

  • HCH CUSP team approach

  • Interventional radiology CUSP

  • Resilience

  • Connecting the dots

Holy cross hospital
Holy Cross Hospital

  • Member of Trinity Health

  • Largest hospital in MD-DC suburbs

    • Founded 1963

    • Primarily serves Montgomery and Prince George’s counties

    • Montgomery County’s only teaching hospital for medical education

    • 455 licensed beds, including 46 in the NICU

    • 1,321 medical staff and 3,062 employees

    • FY11 annual discharges: 33,210

      • Outpatient registrations: 170,317

      • Surgeries: 13,281

      • Emergency center: 88,121

Hch patient safety initiatives
HCH Patient Safety Initiatives

  • Perinatal Patient Safety Initiative

  • Stamp Out Sepsis campaign

  • Hiring experienced nurses

  • ICU multidisciplinary rounds

  • Mandatory influenza immunization

  • OR universal protocol

  • Patient Safety Committee

  • Root cause analysis, FMEA

  • Fall prevention

  • Etc., etc., etc.

Fall 2010
Fall 2010

  • Duke Patient Safety Course

  • December 2010 AHRQ Survey

  • Maryland Hospital Association

    • CLABSI-CUSP Collaborative

  • Make CUSP teams the tool

  • Invite Bryan Sexton to Holy Cross


  • Focus on local processes and “defects of care”

  • Frontline patient safety leader

  • Area manager

  • Physician champion

  • Executive partner

    • Frontline staff

    • Other key personnel (e.g., RT in ICU)

Selecting cusp teams
Selecting CUSP Teams

  • CLABSI-CUSP Collaborative

    • SICU and ICU/CCU

  • Lower perception of safety scores

    • Pharmacy, Gen Surg, OR, Medicine, PCU, ER

  • Paired Units

    • IMC/CIC and HRP/L&D

  • Recent significant events

    • Interventional Radiology

  • Inpatient units without CUSP Teams

    • Joint & Spine, Women’s Surgery, Oncology, ASD

    • Maternity, NICU, Peds, Observation

April 2011
April 2011

Three-day patient safety training – 94 individuals

Five one-hour frontline staff patient safety sessions

Grand rounds on patient safety

Medical Executive Committee dinner

“Safety as a System” video at orientation and on HCH intranet

Cusp teams
CUSP Teams


Gen Surg

11 CUSP Teams representing 14 units and 68% of frontline staff


5 Medicine



Emer Center

L&D and HRP



Int Rad

Cusp team activities
CUSP Team Activities

  • Team meets 1-2 times per month

  • Separate Executive Rounds with patient safety leader (PSL)

  • Work on a few defects at a time

    • Hand hygiene

    • Hand offs and transitions in care

    • Patient identification

    • Standardization of care practices

    • Supplies and equipment

    • Orders management

  • Protected time for patient safety leader

  • CUSP All Teams Meeting

Learning from defects
Learning From Defects

What happened?

Brief defect description

Why did it happen?

System factors; e.g., staffing, workload, equipment, production pressure, training, fatigue, physical environment, etc.

What can we do to reduce the risk of it recurring with different caregivers?

How will we know the risk was reduced?

With whom should we share our learning?

Directed defects work
Directed Defects Work

  • Hand hygiene

    • One hour per month “secret shopper” from each patient safety leader for three months

  • CLABSI — Critical care units

  • CAUTI — Med/surg units

  • CLABSI/VAP/CAUTI defects tool — ICUs

Protected time for psl
Protected Time for PSL

  • Budgeted up to 12 hours per month

    • Charged to patient safety

  • Schedule with manager

  • Have a plan for the time

    • Shadowing on unit

    • Shadowing off unit

    • Direct observation

    • Peer interviews

    • Defects of care

    • Data collection

  • Send summary of day’s activity to Dr. Phillips

Cusp all teams meeting
CUSP All Teams Meeting

  • Bimonthly at two different times and days

  • PSLs, managers, and physicians

  • Review tools and reports

  • Review protected time use

  • Share experiences and barriers

Interventional radiology cusp
Interventional Radiology CUSP

  • Medication errors

    • Emphasize double verification

    • Direct observation

    • High alerts meds JIT

  • Outdated devices

    • Inventory label alert

    • Double confirmation

  • Consents

  • Protected time

Sustaining cusp
Sustaining CUSP

  • Maturing Patient Safety Leaders (PSLs)

  • Using protected time

  • Protecting the CUSP charter

  • Engaging physicians and executives

  • Using the tools without a CUSP team

  • Chartering new CUSP teams

  • Training new team members

  • Keeping organizational focus

Focusing our organizational efforts
Focusing Our Organizational Efforts

  • Key outcomes

    • Actively engaged staff

    • Overall perception of safety

  • Key drivers

    • Communication openness

    • Staff burnout

Organizational initiatives
Organizational Initiatives

  • CUSP teams

  • Staff retention and performance

    • Pay structure and clinical ladder

    • Decreased agency

  • Web-based error reporting system

  • Just Culture principles

  • Resilience Resource Team


  • Ability to recover from or adjust easily to misfortune or change

  • Ability to become strong, healthy, or successful again after something bad happens

  • 4 F’s: friends, family, faith, fitness

  • Resilience Resource Team

    • Identify, organize, and communicate about existing resources to combat burnout

    • Develop new initiatives that increase resilience

Connecting the dots
Connecting the Dots

Just Culture

Open Communication


CUSP Teams

Actively Engaged Staff

Staff Retention

Patient Safety

Upper chesapeake health maryland
Upper Chesapeake Health, Maryland

Jim Hursey, MBA, Sr. VP, COO

Judi Webster, RN, BSN, PI Patient Safety Coordinator

Upper chesapeake health maryland1
Upper Chesapeake HealthMaryland

  • Two acute care, not-for-profit hospitals -- Upper Chesapeake Medical Center in Bel Air and Harford Memorial Hospital in Havre de Grace, 30-40 miles northeast of Baltimore.

  • Affiliated with the University of Maryland Medical System

  • Total of 272 licensed beds and combined total of over 90,000 ED visits and 1,400 deliveries annually

  • Almost 3,000 team members and over 600 medical staff physicians

Senior leadership commitment
Senior Leadership Commitment

  • Establish the culture of safety

    • Senior leadership support is the key to success

    • Expectations set for leaders and team members

      • Patient safety incorporated into the culture of excellence philosophy and strategic plan

        • Starts in orientation of new team members

          • Josie King video for all TM

          • Science of safety video for clinical and security TM

            • Ensure administrative polices are in place to support a culture of safety and just culture

            • Stop the Line Policy

Senior leadership commitment1
Senior Leadership Commitment

  • Facilitate improvements by providing resources

    • Support nonproductive time for participation in collaborative meetings, conference calls, education, and data gathering for frontline TM and leadership

  • Model behaviors important to the culture of safety

    • Support speak-up and provide nonthreatening environment

  • Participate in patient safety walkabouts and collaborative executive rounding

    • Listen to TMs

Our journey
Our Journey

  • Started biannual patient safety “walkabouts” in the summer of 2010 in all departments and nursing units as part of the evidenced-based Patient Safety Initiative

    • Introduced the concept of patient safety walkabouts and presented short agenda of “hot topics”

    • To stimulate open discussion, we used the results of AHRQ Patient Safety Culture Survey completed in December 2009

Our journey1
Our Journey

  • CUSP:CLABSI Collaborative Project started November 2010, calling for monthly rounds in ICUs

    • Used staff safety assessment as the basis for initial talking points for senior leadership to create a less threatening environment

    • Open forum for discussion of concerns

Flexibility is a necessity
Flexibility is a Necessity

  • Began by scheduling one hour in each ICU, at each facility, every month

    • Difficult for senior leaders’ scheduling

      • “Schedule-keeper” needs to understand the importance of making walkabouts a priority

      • 60 minutes is too long for all involved – Clinical TM could not be away from patients that long, senior leaders running to next meeting – very stressful for all

Current process
Current Process

  • Monthly ICU rounds

    • 30-minute sessions; can accomplish everything in about 20 minutes on the ICUs

  • Quarterly rounds to remainder of departments/nursing units

  • Invite all TM to participate – EVS, Dietary, Rehab, Respiratory and Vascular Access Team, etc., are encouraged to participate in walkabouts on the nursing units when they are there – dates and times advertised and sent to managers and directors for communication

  • All levels of leadership and PI Patient Safety Coordinator participate

  • Use a grid to track issues

Accountability the grid
Accountability- The Grid

  • Created a spreadsheet for each unit/department

  • PI Patient Safety Coordinator records all issues presented and maintains the grid

  • Leadership is assigned to follow up on the item, their VP notified

  • Target completion dates are assigned

  • Spreadsheet is emailed to all leaders for their follow up and posting in each unit/department TM common area

    • Some issues (process) are referred to Unit-Based Nurse Practice Councils or the larger Nurse Practice Council for resolution.

  • Leaders send updates for the spreadsheet as items/issues are resolved

  • Leaders responsible for communicating grid to TM

Walkabout agenda
Walkabout Agenda

  • Short agendas are good

  • We start with a topic that is a patient safety goal

  • Hot topics

  • Share stories

  • Review status of open issues from previous visits

  • Open Discussion of TM patient safety concerns

    • Listen to all concerns

    • Ask for solutions

      • Charge nurse phones & alarm fatigue

      • RRT Responders Medication Access

Final thoughts
Final Thoughts

  • It’s a marathon, not a sprint

  • Find what works for you and your culture

  • Involve physician leadership

  • Value team members – they have lots of great ideas