slide1 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Comprehensive Unit-Based Safety Program (CUSP) PowerPoint Presentation
Download Presentation
Comprehensive Unit-Based Safety Program (CUSP)

Loading in 2 Seconds...

play fullscreen
1 / 45

Comprehensive Unit-Based Safety Program (CUSP) - PowerPoint PPT Presentation


  • 218 Views
  • Uploaded on

Terri Conner, Ph.D. Nybeck Analytics Partnership for Patients Initiative at Texas Center for Quality & Patient Safety. Comprehensive Unit-Based Safety Program (CUSP). Central Line Associated Blood Stream Infections. GOALS.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Comprehensive Unit-Based Safety Program (CUSP)' - jalen


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1
Terri Conner, Ph.D.

Nybeck Analytics

Partnership for Patients Initiative at

Texas Center for Quality & Patient Safety

Comprehensive Unit-Based Safety Program (CUSP)

Central Line Associated Blood Stream Infections

goals
GOALS

Work to eliminate central-line associated blood stream infections (CLABSI) in your unit

Improve safety culture

Learn from defects

evidence based behaviors to prevent clabsi
EVIDENCE-BASED BEHAVIORS TO PREVENT CLABSI

Remove unnecessary lines

Wash hands prior to procedure

Use maximal barrier precautions

Clean skin with chlorhexidine

Avoid femoral lines

4e s to ensuring patients receive evidence
4E’S TO ENSURING PATIENTS RECEIVE EVIDENCE
  • Engage
    • How does this make the world a better place?
  • Educate
    • What do we need to know?
  • Execute
    • What do we need to do?
    • What keeps me from doing it?
    • How can we do it with our resources and culture?
  • Evaluate
    • How do we know we improved safety?
engage
ENGAGE
  • CLABSIs associated with significant morbidity, mortality, and costs
  • Patients in ICUs are at an increased risk
    • 48% of ICU patients have indwelling central venous catheters
    • 15 million central line days per year in United States ICUs
    • As many as 28,000 ICU patients die from CLABSIs annually in the U.S. alone.
engage1
ENGAGE

Share about a patient who was infected

Post baseline rates of infections

Estimate number of deaths and dollars from current infection rates

Remind staff that most CLABSI are preventable

educate
EDUCATE

Conduct in-service regarding CLABSI prevention

Create forum to jointly educate physicians and nurses

Add CLABSI prevention to ICU orientation

Give staff fact sheets, articles, and slides of evidence

execute
EXECUTE
  • Standardize and reduce complexity: Create line cart
  • Create independent checks: Create BSI checklist
  • Ask providers daily whether catheters could be removed
  • Empower nurses to ensure physicians comply with checklist
    • Nurses can stop takeoff
  • Learn from mistakes: review every infection
evaluate
EVALUATE

Monitor rates of infections using CDC definitions

Post rates of infections per year in the unit

Post number of weeks or months without an infection

slide10
CUSP

Comprehensive Unit-based Safety Program

An intervention to learn from mistakes and improve safety culture

A good approach whenever there is a gap between evidence-based practice and current practice on your unit.

cusp emphasis on culture
CUSP: EMPHASIS ON CULTURE
  • Shared attitudes, values, goals, practices, behaviors
  • Culture influences behavior
    • Participation in quality improvement efforts
    • Communication
      • Breakdown in communication contributes to nearly all adverse events.
cusp comprehensive unit based safety program
CUSP: COMPREHENSIVE UNIT-BASED SAFETY PROGRAM

Safety practices part of daily work

Implemented at the unit level

Led by clinicians

Structured program, yet flexible

pre cusp steps
PRE-CUSP STEPS
  • Assemble Safety Team
    • Multidisciplinary
    • Different levels of experience
    • Encourage joining team at any phase of the program
pre cusp steps1
PRE-CUSP STEPS
  • Team Members
    • Project Leader (Unit Champion)
    • Nurse Manager
    • Physician Champion
    • Senior Hospital Executive
    • Patient Safety Coordinator
    • Epidemiology / Infection Control
    • Coach
pre cusp steps2
PRE-CUSP STEPS
  • Measure Safety Culture
    • Before CUSP implementation, and then every 12-18 months
    • Use AHRQ’s The Hospital Survey on Patient Safety Culture (HSOPS)
    • All clinical and non-clinical providers
    • Report results to the unit and senior hospital executive
cusp steps
CUSP STEPS

Science of safety training

Identify defects

Assign executive to adopt unit

Learn from defects

Implement teamwork tools

step 1 science of safety training
STEP 1: SCIENCE OF SAFETY TRAINING
  • Goals
    • Magnitude of patient safety problem
    • Foundation for investigating safety defects
    • Providers’ involvement significantly affects patient safety
step 1 science of safety training1
STEP 1: SCIENCE OF SAFETY TRAINING
  • Learning Objectives
    • Safety is a property of the system
    • Use strategies to improve system performance
      • Standardize work
      • Create independent checks for key processes
      • Learn from mistakes
    • Apply strategies to both technical work and team work
    • Teams make wise decisions with diverse and independent input
step 1 science of safety training2
STEP 1: SCIENCE OF SAFETY TRAINING
  • Training Session
    • 3-part “Improving Safety” presentation by Dr. Peter Pronovost
      • Part 1: http://www.youtube.com/watch?v=GOJJHHm7lnM
      • Part 2 - http://www.youtube.com/watch?v=wpzb7nM6oFQ&feature=related
      • Part 3 - http://www.youtube.com/watch?v=6BnXs4KtER8&feature=related
    • Instruct staff on reporting of safety concerns
    • Describe executive safety rounds
step 2 identify defects
STEP 2: IDENTIFY DEFECTS

Eyes and ears of patient safety

Ongoing process

Disseminate Staff Safety Assessment Form

Combine results and prioritize defects

what is a defect
WHAT IS A DEFECT?

Anything you do not want to have happen again.

Blood stream infections are almost always preventable. They should be viewed as defects.

step 2 identify defects1
STEP 2: IDENTIFY DEFECTS
  • Staff Safety Assessment Form
    • Purpose: Tap into your knowledge and experiences at the frontlines of patient care to find out what risks are present on your unit that do or could jeopardize patient safety.
    • All health care providers in the unit complete this form.
    • 2-item questionnaire
step 2 identify defects2
STEP 2: IDENTIFY DEFECTS
  • Staff Safety Assessment Form
    • Please describe how you think the next patient in your unit/clinical area will be harmed.
    • Please describe what you think can be done to prevent or minimize this harm.
step 2 identify defects3
STEP 2: IDENTIFY DEFECTS
  • Combine Results
    • Group into common types of defects
      • Communication
      • Medication process
      • Patient falls
      • Supplies
    • Frequency distributions
      • Example: communication, 57%
step 2 identify defects4
STEP 2: IDENTIFY DEFECTS
  • Prioritize safety concerns
    • Obtain input from CUSP team senior executive
    • Prioritize based on
      • Likelihood of causing patient harm
      • Severity of harm
      • How common is the problem
      • Likelihood it can be solved by implementing a daily work process
step 4 learn from defects
STEP 4: LEARN FROM DEFECTS

Four Key Questions

  • What happened?
  • Why did it happen?
  • What will you do to reduce the chance it will recur?
  • How do you know that you reduced the risk that it will happen again?
what happened
WHAT HAPPENED?

Reconstruct the timeline and explain what happened

Put yourself in the place of those involved, in the middle of the event as it was unfolding

Try to understand what they were thinking and the reasoning behind their actions/decisions

Try to view the world as they did when the event occurred

why did it happen system failures
WHY DID IT HAPPEN?SYSTEM FAILURES

Arise from managerial and organizational decisions that shape working conditions

Often results from production pressures

Damaging consequences may not be evident until a “triggering event” occurs

Develop lenses to see the system factors that lead to the event

what will you do to reduce the risk of it happening again
WHAT WILL YOU DO TO REDUCE THE RISK OF IT HAPPENING AGAIN?
  • Prioritize most important contributing factors
  • Prioritize most beneficial interventions
  • Safe design principles
    • Standardize what we do
    • Create independent check
    • Make it visible
  • Safe design applies to technical and team work
what will you do to reduce the risk of it happening again1
WHAT WILL YOU DO TO REDUCE THE RISK OF IT HAPPENING AGAIN?
  • Develop list of interventions
  • For each intervention:
    • Rate how well the intervention solves the problem or mitigates the contributing factors for the accident
    • Rate the team belief that the intervention will be implemented and executed as intended
  • Select top interventions (2 to 5) and develop intervention plan
    • Assign person, task follow-up date
how do you know risks were reduced
HOW DO YOU KNOW RISKS WERE REDUCED?
  • Did you create a policy or procedure?
  • Do staff know about policy or procedure?
  • Are staff using the procedure as intended?
    • Behavior observations, audits
  • Do staff believe risks were reduced?
step 4 learn from defects1
STEP 4: LEARN FROM DEFECTS
  • Summarize and Share Findings
    • Learning from Defects Tool
      • Detailed form for each incident or identified defect
    • Case Summary Form
      • Summarize the case
      • Identify system failures
      • Identify opportunities for improvement
      • List actions taken to prevent future harm
    • Share your findings
examples
EXAMPLES

Defect: Nasoduodenal tube placed in lung

Intervention: Protocol developed for NDT placement

Defect: Bronchoscopy cart missing equipment

Intervention: Checklist developed for stocking cart

Defect: Inconsistent use of Daily Goals rounding tool.

Intervention: Gained consensus on required elements of Daily Goals rounding tool.

step 4 learning from defects
STEP 4: LEARNING FROM DEFECTS

Key Points

  • Focus on systems, not people
  • Prioritize
  • Go mile deep and inch wide, rather than mile wise and inch deep
  • Pilot test
  • Learn from 1 defect a quarter
  • Answer the four questions
step 5 team work tools
STEP 5: TEAM WORK TOOLS

Staff Safety Assessment

Safety Issues Worksheet

Status of Safety Issues

Learning from Defects Tool

Case Summary Form

Daily Goals Checklist

Morning Briefing Tool

Shadowing Another Professional

Observing Rounds

staff safety assessment
STAFF SAFETY ASSESSMENT

Used to identify defects in the unit

Please describe how you think the next patient in your unit/clinical area will be harmed.

Please describe what you think can be done to prevent or minimize this harm.

learning from defects
LEARNING FROM DEFECTS
  • Explain what happened.
  • Check off the factors that negatively or positively contributed to the incident.
  • Describe how you will reduce the likelihood of this defect happening again by completing the tables.
  • Develop interventions, and choose 2-5 to implement.
    • What will be done?
    • Who will lead the intervention?
    • When is follow-up?
  • Describe how you know you have reduced the risk.
  • Summarize your findings using the Case Summary Form.
case summary form
CASE SUMMARY FORM

Form Sections

Safety tips

Case summary

System failures

Opportunities for improvement

Actions taken to prevent harm

daily goals checklist
DAILY GOALS CHECKLIST

Care plan for patients

Lists needs for the day to safely move a patient closer to discharge

Used to improve communication among care team members and family members.

Use during morning and evening rounds, and kept at patient’s bedside.

Adapt to your own unit’s environment.

morning briefing tool
MORNING BRIEFING TOOL
  • Structured approach to assist physicians and charge nurses in identifying the problems that occurred during the night and potential problems during the clinical day.
  • Tool used by:
    • Physicians who conduct patient rounds
    • Charge nurses and nurse managers who make patient assignments
  • Complete this tool daily prior to starting patient care rounds by meeting with the charge nurse.
shadowing another professional
SHADOWING ANOTHER PROFESSIONAL
  • Designed to provide a structured approach to identify communication, collaboration and teamwork defects among different practice domains.
  • Purpose: to improve teamwork, collaboration, and communication that affect patient care delivery
  • Who should use this tool?
    • Anyone on the CUSP team
    • Staff unfamiliar with responsibilities and practice domains of another profession
    • Executive team member may want to shadow practitioners
  • Recommended when <60% of unit members report good teamwork or good safety climate.
observing rounds
OBSERVING ROUNDS
  • Purpose: Provide a structured approach for improving teamwork, and communication behaviors across and between disciplines that negatively affect staff morale and patient care delivery.
  •  Who Should Use this Tool?
    • Physicians who conduct patient rounds.
    • Administrators, house officers, nurses, pharmacists, respiratory therapists, medical and nursing students
      • better understand the dynamics of multidisciplinary rounds
      • identify defects in communication
      • foster collaboration among disciplines or practice domains
      • target areas where communication can be improved in the rounding process and in setting patient daily goals