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CUSP for Safe Surgery (SUSP) Kickoff Webinar. April 28 , 2014 and April 30, 2014. Some quick administrative announcements. You need to dial into the conference line to hear audio: Dial in Number: 1-800-311-9401 Passcode: 83762

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april 28 2014 and april 30 2014
CUSP for Safe Surgery (SUSP)

Kickoff Webinar

April 28, 2014 and April 30, 2014

some quick administrative announcements
Some quick administrative announcements
  • You need to dial into the conference line to hear audio:
    • Dial in Number: 1-800-311-9401
    • Passcode: 83762
  • Please contact your Coordinating Entity for a copy of these slides if you have not already received them
  • We will make a recording of this webinar available to you.
  • We want you to interact with us today. You can:
    • Type comments in the chat box.
    • Or even better, speak up.

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it is the only thing that ever has.

-- Margaret Mead

susp kickoff agenda
SUSP Kickoff Agenda
  • Introductions
  • SUSP Project Overview
  • Building your SUSP Team
  • Intro to Building and Measuring Safety Culture
  • Current Team Experiences
  • Next Steps

Peter Pronovost,


Principal Investigator

Charles Bosk, PhD

Principal Investigator


Cliff Ko,


Principal Investigator


Liza Wick, MD

State Coach

Content Expert

Bradford Winters, MD

State Coach

Content Expert

Julius Pham, MD, PhD

State Coach

Content Expert

Deb Hobson, RN

State Coach

Content Expert


Mike Rosen, PhD

State Coach

Content Expert

Sallie Weaver, PhD

State Coach

Content Expert

Sean Berenholtz,


State Coach

Content Expert

Lisa Lubomski, PhD

State Coach

Content Expert


Tricia Francis, MA, MS, PMP

SUSP Project Manager

Kathryn Taylor, RN, MPH

SUSP Program Manager

Kristina Weeks, MHS



Cathy Van De Ruit, PhD


Jeremiah Bowman

American College of






Nasir Ismail, MS

SUSP Safety Culture Coordinator

Mary Twomley, MS

SUSP Senior Research Coordinator

Laura Vail, MS

SUSP IT Specialist

Erin Hanahan, MPH

SUSP Senior Research Coordinator

poll who is on the call
Poll – Who is on the call?

What is your role in your clinical area?

  • Surgeon
  • Quality improvement practitioner
  • Infection preventionist
  • OR Nurse
  • OR technician
  • Anesthesiologist
  • OR manager
  • Other
learning objectives
Learning Objectives

After this session, you will be able to:

  • Distinguish SUSP approach from that of other national improvement projects
  • Describe the connection between SUSP and safety culture work as structured in the Comprehensive Unit-based Safety Program (CUSP)
  • List the steps for developing a local SSI prevention bundle

DRAFT – final pending AHRQ approval

why is your susp work important 1
Why is Your SUSP Work Important?1
  • 1 in 25 people will undergo surgery
  • 7 million (25%) complications follow in-patient surgeries
  • 1 million (0.5 – 5%) deaths follow surgery
  • 50% of all hospital adverse events are linked to surgery AND are avoidable
respond in the chat

Engagement Questions

Respond in the chat.

In our institution, near perfect compliance with SCIP measures did not result in decreased SSI rates.

  • Have other people on the call observed the same trends?
  • Why might that be?
susp is cusp for safe surgery

What is SUSP?

SUSP is CUSP for Safe Surgery
  • National improvement effort
  • Designed to reduce surgical site infections (SSI) and other surgical complications.
  • CUSP is the acronym for “Comprehensive Unit-based safety program”

What is SUSP?

  • This project will teach you to embed adaptive work (CUSP) in your technical work (surgical care).
  • Unlike other SSI prevention projects, you will develop your own SSI prevention ‘bundle.’
    • There is no one ‘right’ bundle for SSI prevention
    • Engage frontline staff to identify local defects
agency for healthcare research and quality

What is SUSP?

Agency for Healthcare Research and Quality

AHRQ-funded project

  • Individual hospitals participate until August 31, 2015
  • Participation is free
  • Participation is open to hospitals
    • Of all sizes
    • In all 50 states
    • For any surgical procedure type
susp enrollment by coordinating entity
SUSP Enrollment by Coordinating Entity

International Hospitals

Located in Canada and UK

our shared project goals
Our Shared Project Goals
  • To achieve significant reductions in surgical site infection and surgical complication rates
  • To achieve significant improvements in safety culture
despite years of technical intervention rates rose

Intervention Requires Technical & Adaptive

Despite years of technical intervention, rates rose


Sentinel Event Alert: Wrong-sided surgery Aug 98

Sentinel Event Alert: Follow-up review of wrong-sided surgery Dec 01

Wrong Site Surgery Summit I Jan 03

Universal Protocol 2004

Wrong Site Surgery Summit II Feb 07

Revised Wrong Site Surgery Definition Jun 10






cusp is a model to guide a daptive work 3

Comprehensive Unit-based Safety Program (CUSP)

CUSP is a model to guide adaptive work3
  • Educate staff on the science of safety
  • Identify defects
  • Partner with a Senior Executive
  • Learn from defects
  • Improve teamwork and communication
how is susp different
How is SUSP different?
  • Informed by science and backed with evidence
  • Led by clinicians and supported by management
  • Guided by national and local measures
  • National implementation tailored to local context
building on previous state level success
Building on Previous State Level Success

Michigan Keystone ICU program

  • Reductions in central line-associated blood stream infections (CLABSI)4,5
  • Reductions in ventilator-associated pneumonias (VAP) 6
  • Improvements in safety climate 7
and national level highlights
…And National Level Highlights

National On the CUSP: Stop BSI program8

  • A national initiative to implement a proven culture change model, CUSP, and interventions to prevent CLABSI.
  • A total of 1,071 ICU’s in 45 states
  • A 43% reduction in CLABSI rates
  • The number of ICU’s that achieved CLABSI rate of zero, more than doubled.
hospital acquired infection rates drop

While Safety Culture Increases

Hospital-acquired Infection Rates Drop
  • “Needs improvement”: Less than 60% of respondents reporting good safety or teamwork culture
  • Statewide in 2004, 82-84% needed improvement, in 2007 22-23%7

Case Study: Laparoscopic GI Surgery Trays


Lap tray had 137 instruments including many unnecessary implements

JHH unionized employees process open instruments, while contractors process lap instruments.

Reduced lap tray instruments by 60% to 54 key instruments.

Fewer instruments to count and turnover saves money and time.





Case Study: Laparoscopic GI Surgery Trays

137 instruments

54 instruments

case study antibiotic irrigation
Case Study: Antibiotic Irrigation


Frontline providers questioned the inconsistent use of antibiotic irrigation between surgeons

Prominent surgeons used antibiotic irrigation

A literature review yielded no evidence to support continued use, so removed from hospital formulary

$537,000annual savings on antibiotic irrigation WITH surgeon buy-in




susp project management guide
SUSP Project Management Guide
    • We have developed monthly modules to guide you through this process.
  • Each module has ‘deliverables’ for your team, to help you keep your work on track.
  • Your Coordinating Entity sets up monthly coaching calls to enable horizontal learning.
    • Share what you learn on state coaching calls.
    • You will learn as much (if not more) from each other as you will from us!

Checking In: Any questions about your Coordinating Entity?

susp project structure
SUSP Project Structure
    • Kick-off / Project Initiation
  • Onboarding Phase (Months 1 – 6)
    • Module 1: How To Use The SUSP Portal: A Training Call for Facilitators
    • Module 2: Train Everyone on the Science of Safety & Identifying Defects
    • Module 3: Engage Senior Executives in SSI Prevention Work
    • Module 4: Debrief your Safety Culture Scores and SSI data
    • Module 5: Build your SSI Prevention Bundle
    • Module 6: Perform an SSI Investigation
  • Implementation Phase (Months 7 – 14)
  • Sustainability Phase (Months 15 – 18)
susp project structure1
SUSP Project Structure
  • Onboarding Phase (Months 1 – 6)
  • Implementation Phase (Months 7 – 14)
    • Module 7: Implement your SSI Prevention Bundle
    • Module 8: Cohort 5 SUSP Team’s Experience
    • Module 9: Emerging Evidence: A Surgeon’s Perspective
    • Module 10: Learn from Defects I
    • Module 11: Learn from Defects II
    • Module 12: Optimize Briefings and Debriefings
    • Module 13: Audit Your Briefing and Debriefing Process
    • Module 14: Annual progress call
  • Sustainability Phase (Months 15 – 18)
susp project structure2
SUSP Project Structure
  • Onboarding Phase (Months 1 – 6)
  • Implementation Phase (Months 7– 14)
  • Sustainability Phase (Months 15 – 18)
    • Module 15: HSOPS Re-administration and Culture Debriefing
    • Module 16: Sustain and Spread Your Surgical Safety Improvements
    • Module 17: Learn From Defects
    • Module 18: Deep Rooting Your Data/Sign Off
polling question
Polling Question

How ready is your organization to enable frontline participation in improvement workand address frontline patient safety priorities?

  • Totally ready
  • Getting ready
  • Not ready at all
  • Not sure
  • World Health Organization. New Scientific Evidence Supports WHO Findings: A Surgical Safety Checklist Could Save Hundreds of Thousands of Lives. http://www.who.int/patientsafety/challenge/safe.surgery/en/. Accessed August 7, 2013.
  • Centers for Medicare and Medicaid Services. National Impact Assessment of Medicare Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NationalImpactAssessmentofQualityMeasuresFINAL.PDF. Published March 2012. Accessed August 7, 2013.
  • The Joint Commission, Sentinel Event Data. http://www.jointcommission.org/assets/1/18/Event_Type_Year_1995-2011.pdf;29. AccessedAugust 8, 2013.
  • Pronovost P, Needham D Berenholtz S, et al. An Intervention to Decrease Catheter-related Bloodstream Infections in the ICU. N Engl J Med. 2007;356(25):2660.
  • Pronovost P, Goeschel C, Colantuoni E, et al. Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study. BMJ. 2010; 340:c309.
  • Berenholtz S, Pham J, Thompson D, et al. Collaborative cohort Study of an Intervention to Reduce Ventilator-associated Pneumonia in the Intensive Care Unit. Infect Control HospEpidemiol. 2011; 32(4): 305–314.
  • Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Medicine. 2011 May;(39(5):934-9.
  • Website of the National Implementation of the Comprehensive Unit-based Safety Program to Eliminate Health Care-Associated Infections. http://www.onthecuspstophai.org/. Accessed August 7, 2013.
  • Wick et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. J Am Coll Surg. 2012; 215 (2).
  • The Joint Commission. J Qual Patient Saf. 2010;36:252-6http://www.ahrq.gov/cusptoolkit/
polling question1
Polling Question
  • Do you have a SUSP team?
    • Yes
    • No
  • If so, who is on your team?
    • Anesthesiologist
    • CRNA
    • Infection Preventionist
    • OR nurse
    • QI lead
    • Scrub tech
    • Senior Executive
    • Surgeon
    • Surgical clinical reviewer
    • Surgical floor nurse
    • other
learning objectives1
Learning Objectives

After this session, you will be able to:

  • Develop a strategy to engage frontline and executive team members in SUSP work
  • Utilize basic strategies to encourage surgeon participation in SUSP work
  • Identify SUSP team members and plan your first meeting

StephMullens CST

Lead Tech

Sean Berenholtz MD

Anesthesia Lead

Renee Demski MBA

Senior Director Quality

Johns Hopkins Medicine

Elizabeth Wick MD

Surgery Lead

Mary Grace Hensel RN

Manager OR

Kevin Driscoll CRNA


Tracie Cometa RN

Lead RN

Deb Hobson RN


Lucy Mitchell RN


perioperative susp team members
Perioperative SUSP Team Members

Essential Team Members

  • Surgeons
  • Anesthesiologists
  • CRNAs
  • Circulating nurses
  • Scrub nurses / OR techs
  • Perioperative nurses
  • Executive partner
  • Nurse leaders

Enhancing Team Members

  • Physician assistants
  • Nurse educators
  • Anesthesia assistants
  • Infection preventionists
  • OR directors
  • Patient safety officers
  • Chief quality officers
  • Ancillary staff
the s usp team
The SUSP Team
  • Understands that patient safety culture is LOCAL
  • Composed of engaged frontline providers who take ownership of patient safety
  • Includes staff members who have different levels of experience
  • Tailored to include members based on clinical intervention
susp team logistics
SUSP Team Logistics
  • Meets regularly
    • Weekly ideal
    • Monthly at a minimum
  • Has adequate resources including protected time
    • 2 to 4 hours per week for a team leader, surgeon, anesthesia, nurse, and infection preventionist
enter response in the chat

Polling Question

Enter response in the chat.
  • How can you protect 2 – 4 hours of time per week for your SUSP team leaders?

Activity:Brainstorm how to prioritize the need for protected time.

s usp teams group processes
SUSP Teams’ Group Processes
  • Role Clarity
  • Norms
  • Effective Team
  • Communication
  • Effective Group Processes
  • Leadership
  • Buy-in and Support
  • Conflict Resolution
  • Education
  • and Engagement
role of senior executive partner
Role of Senior Executive Partner
  • Helps the team prioritize improvement efforts
  • Helps the team navigate organizational bureaucracy
  • Ensures the SUSP team has resources to fix problems
  • “Comes out of the office” to meet monthly with members of health care team in their clinical area
finding an executive partner
Finding an Executive Partner
  • Contact hospital management to determine which senior executive will best fit the perioperative area and the following criteria:
    • Director level or above
    • Available to round for at least one hour per month
    • Approachable and comfortable with sensitive topics
  • Set up a meeting to introduce the project, provide a tour of the perioperative area, and share unit-level information
role of surgeon leader
Role of Surgeon Leader
  • Serves as role model for SUSP activities
  • Meets with SUSP team at least monthly
  • Participates in monthly senior executive partnership meetings
  • Communicates with physician group as needed
  • Assists with implementation of interventions
engage surgeons on the susp team
Engage Surgeons on the SUSP Team
  • Identify surgeon leaders
  • Explain this role
  • Listen to surgeon concerns
  • Develop plans to address concerns
  • Reward surgeon leaders
  • Determine best vehicle for communication
  • Formalize plan for communications
practical tips for scheduling susp meetings
Practical Tips for Scheduling SUSP Meetings
  • Incorporate SUSP meetings into ongoing educational activities to ease scheduling challenges
    • Regularly scheduled nurse training
    • Grand rounds for physicians
    • Invite RNs to join grand rounds
  • Offer incentives for participating
next steps
Next Steps
  • Recruit a team lead, nurse lead, surgeon lead, and executive partner along with other team members
  • List team member names and contact information on the CUSP for Safe Surgery Team Member Form and post the form in a central location
  • Schedule your SUSP meetings for 6 to 12 months
  • Complete CUSP for Safe Surgery Roles and Responsibilities Form during your first meeting
polling question2
Polling Question

Do you think that your team can influence your organization to enable frontline participation in improvement workand address frontline patient safety priorities?

  • We can definitely influence our organization
  • We might be able to influence our organization
  • We can’t influence our organization
  • Not sure
learning objectives2
Learning Objectives

After this session, you will be able to:

  • Define safety culture
  • Describe why a safety culture is important for improvement efforts
  • Explain the SUSP safety culture measurement process
what is safety culture
What is Safety Culture?
  • Perceived priority of safety relative to other goals
  • Culture is the compass team members use to guide their behaviors, attitudes, & perceptions on the job
    • What will I get praised for?
    • What will I get reprimanded for?
    • What is the “right” thing to do?

Culture provides the context for team success.

Image source: Marysia Tomaszewska, August 8, 2012, used under a Creative Commons License

safety culture is related to outcomes 2 3 4 5 6 7 8

Why Safety Culture Matters

Safety Culture Is Related To Outcomes2,3,4,5,6,7,8
  • Patient outcomes
    • Patient care experience
    • Infection rates, sepsis
    • Postoperative hemorrhage, respiratory failure, accidental puncture / laceration
    • Treatment errors
  • Clinician outcomes
    • Incident reporting, burnout, turnover
why safety culture matters 9 10 11 12
Why Safety Culture Matters9,10,11,12
  • Safety culture influences the effectiveness of other safety and quality interventions
    • Can enhance or inhibit effects of other interventions
  • Safety culture can change through intervention
    • Best evidence for culture interventions that use multiple components
cusp safety culture
CUSP & Safety Culture
  • Measure safety culture at the start of the SUSP project
    • Provides a baseline to diagnose barriers and facilitators that can impact improvement efforts
    • Then will bemeasured again 12 months following start of improvement efforts
  • Use reliable and valid survey instrument
    • Hospital Survey on Patient Safety (HSOPS)
  • CUSP is a proven intervention that will help you improve your culture results
polling question3
Polling Question
  • Has your hospital collected data about your work area’s culture of safety in the previous 12 months?
    • Yes
    • No
    • Not sure
have existing hsops data
Have Existing HSOPS Data?

Have you collected data about the safety culture in the last twelve months? If yes:

key role of hsops survey coordinator
Key Role of HSOPS Survey Coordinator

Tip:SUSP Online Portal can be found at https://armstrongresearch.hopkinsmedicine.org/susp.aspx

  • Coordinate entire HSOPS survey administration process
  • Work with hospital and work area leadership to distribute survey materials and information
  • Facilitate survey completion and answer any questions
  • Participate in training webinars and conference call to learn how to use the SUSP Online Portal
  • Enter data from all work area(s) completing the HSOPS survey in the SUSP Online Portal
  • Monitor survey response rate in the SUSP Online Portal
next steps1
Next Steps
  • Complete the SUSP Portal Registration Form, if you have not already done so
  • Identify an HSOPS Survey coordinator to attend a training call
    • May 12th (10 - 11am EDT) or
    • May 14th (4 - 5pm EDT)
  • Determine if your hospital has completed a safety culture survey in the past 12 months
  • Cohort 5 teams will collect and upload HSOPS data during the following times:
    • Baseline: May 12th through July 7th, 2014
    • Follow-up: May 20th through July 9th, 2015

Schein E. Organizational culture and leadership, 4th edition. San Francisco, CA: Jossey-Bass. 2010.

Huang DT, Clermont G, Kong L, Weissfeld LA, Sexton JB, Rowan KM, Angus DC. Intensive care unit safety culture and outcomes: a US multicenter study. Int J Qual Health Care. 2010 Jun;22(3):151-61.

MacDavittK, Chou SS, Stone PW. Organizational climate and health care outcomes. JtComm J Qual Patient Saf. 2007 Nov;33(11 Suppl):45-56.

MardonRE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf. 2010 Dec;6(4):226-32.

Singer SJ, Falwell A, Gaba DM, Meterko M, Rosen A, Hartmann CW, Baker L. Identifying organizational cultures that promote patient safety. Health Care Manage Rev. 2009 Oct-Dec;34(4):300-11.

SorraJ, KhannaK, Dyer N, MardonR, Famolaro T. Exploring Relationships Between Patient Safety Culture and Patients' Assessments of Hospital Care. J Patient Saf. 2012 Jul 10. [Epub ahead of print].


Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

Weaver SJ. A configural approach to patient safety climate: The relationship between climate profile characteristics and patient safety. Doctoral dissertation. University of Central Florida. 2011.

Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Dziekan G, Herbosa T, Kibatala PL, Lapitan MC, Merry AF, Reznick RK, Taylor B, Vats A, Gawande AA; Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ QualSaf. 2011 Jan;20(1):102-7.

MorelloRT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ QualSaf. 2012 Jul 31. [Epub ahead of print]


Van Noord I, de Bruijne MC, Twisk JW. The relationship between patient safety culture and the implementation of organizational patient safety defences at emergency departments.. Int J Qual Health Care. 2010 Jun;22(3):162-9.

Weaver, S. J., Dy, S., Lubomski, L., & Wilson, R. Promoting a culture of safety. In R.M. Watcher, P.G. Shekelle, P. Pronovost (Eds.). Making healthcare safer: A critical analysis of the evidence of patient safety practices (AHRQ report # TBD). Rockville, MD. In press.

john muir medical center

SUSP Team Experience

John Muir Medical Center

John Muir Medical Center

SUSP Experience Video

polling question4
Polling Question

What percentage of organizational change efforts fail?

  • 0 - 20%
  • 21 - 40%
  • 41 - 60%
  • 61 - 80%
  • 81 - 100%
preparing to lead
Preparing to Lead
  • In a postmortem, an autopsy is performed to learn why a patient died. While it may be helpful to those interested in the results, it does not help the central figure in the medical drama—the patient.
  • The PreMortem Exercise is used to identify potential barriers and vulnerabilities to project success before they occur. It builds intuition and sensitivity to future problems.
step 1

Premortem Exercise

Step 1
  • Imagine that we are 2 years into the future and, despite all of the team’s efforts, the project has failed—catastrophically. Things have gone completely wrong on a number of fronts.
  • Now, ask:
    • What does the worst case scenariolook like?
step 2

Premortem Exercise

Step 2
  • Generate the reasons for failure.
  • Spend 10 minutes recording the reasons you believe this failure occurred.
  • Now, ask:
    • What could have caused our project to fail?
step 3

Premortem Exercise

Step 3
  • Prioritize your list of potential reasons for failure.
  • Address the top 2 or 3 concerns.
  • Now, ask:
    • What specific actions can you take to avoid or manage these concerns?
step 4

Premortem Exercise

Step 4
  • Throughout your project, periodically review the potential problem list with your team.
  • This process will raise team awareness to problems that may be emerging and allow them to anticipate solutions.
premortem summary
Premortem Summary
  • Two years out, what does the worst case scenario look like?
  • What could have caused your project to fail?
  • What specific actions can you take to avoid or manage these issues?
  • Review and anticipate potential problems throughout the project.
susp portal project planning resources
SUSP Portal Project Planning Resources
  • Coaching call schedule for your Coordinating Entity
  • SUSP Project Management Guide
  • CUSP for Safe Surgery Team Membership Form
  • CUSP for Safe Surgery Roles and Responsibilities Form
  • Webinar archives

URL: SUSP Online Portal can be found at https://armstrongresearch.hopkinsmedicine.org/susp.aspx

summary of next steps
Summary of Next Steps
  • Return SUSP Portal Registration Form
  • Identify an HSOPS Survey coordinator to attend a training call
    • May 12th (10-11am EDT) or
    • May 14th (4-5pm EDT)
  • Schedule your Kickoff SUSP meeting
    • List team members and contact information on the CUSP for Safe Surgery Team Membership Form and post in centrally
    • Complete CUSP for Safe Surgery Roles and Responsibilities Form during your first meeting
  • Complete the pre-mortem exercise and prepare to share your findings during coaching call
remember we are here to help
Remember, We Are Here To Help!
  • Ask questions during coaching calls
  • Contact the SUSP helpdesk at susp@jhmi.edu
kickoff webinar evaluation
Kickoff Webinar Evaluation

Your feedback is very important to us.

Please take the time to help us understand how to best support you.