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Impact of Comprehensive Unit Based Safety Program(CUSP) on Safety Culture of Non-Intensive Care Units . Roshan Jan Muhammad Preceptor: Melinda Sawyer, MSN, RN, CNS-BC Assistant Director, Patient Safety. Background.

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Impact of Comprehensive Unit Based Safety Program(CUSP)on Safety Culture of Non-Intensive Care Units

Roshan Jan Muhammad

Preceptor: Melinda Sawyer, MSN, RN, CNS-BC

Assistant Director, Patient Safety

  • 13.5% of hospitalized Medicare beneficiaries experience adverse events during their hospital stays that include hospital associated infection, medications errors, falls etc. Of which, 44% adverse events and related harm events are likely preventable.

(DHHS, 2010)

  • More than one third of patients who sustain hospital associated adverse events develop temporary or permanent disability and up to 20.8% of patients die.
  • (Andres-Andres et al., 2009 & Zegers et al., 2009)
  • Safety culture has emerged as an important factor that contributes to quality and safety of care provided and the clinical outcomes of patients in the hospital.

(Pronovost et al., 2006; Kirwan et al., 2013; Watcher, 2008 ,

Singer et al., 2009; Mardon et al., 2010 & Sexton et al., 2006)

  • Joint Commission and Institute of Medicine (IOM) committee requires health care organizations to measure and improve organization’s safety culture.

(The Joint Commission, 2010,; Christine et al., 2010)

safety culture and its significance
Safety Culture and its Significance
  • “Safety culture of the organization is the product of individual and group values, attitude, perceptions, competencies, and the patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management”

Christine et al., 2010,

  • Measured by a valid instrument called “Safety Attitude Questionnaire (SAQ)”

Sexton et al, (2006)

Chaboyer, 2013

Kirwanet al, 2013

Ausserhofer et al., 2013

cusp and safety culture a literature review
CUSP and Safety Culture: A Literature Review



problem statement and question
Problem Statement and Question
  • Most of the CUSP successes are reported in intensive care settings. Johns Hopkins Hospital has replicated CUSP as a quality improvement measure in many non ICU units in over last few years to improve patient’s safety. The impact of CUSP in adult medical surgical units is not exclusively examined.
  • This outcome analysis project aimed to assess if CUSP is associated with improvement in safety culture of adult/pediatric non-intensive care medical surgical units of Johns Hopkins Hospital.


  • Design: retrospective cross sectional
  • Setting: In-patient non-critical units at JHH.
  • Inclusion Criteria
    • In-patient CUSP units
    • Implemented CUSP between 2006-2010
    • SAQ results available before and after CUSP kick off
  • Exclusion Criteria
    • Intensive care units
    • Units merged or split during 2006-2010
    • Missing pre or post CUSP SAQ results
  • Sample Size: Eight non-intensive care adult/pediatric in-patient units
  • Data Collection and Database:
    • SAQ results retrieved from vendor based soft ware “Pascal Matrix” and excel reports.
    • CUSP kick off dates of units from quality departments.
    • Created a surrogate database on excel according to our project variables.
  • Variables
    • Independent variable: CUSP
    • Dependent variables: Seven safety domains of SAQ
  • Statistical Analysis: Paired t-test


unit specific pre and post cusp safety attitude questionnaire saq results
Unit specific Pre and Post CUSP Safety Attitude Questionnaire (SAQ) Results (%)
  • CUSP has shown statistically non-significant but clinically encouraging improvement in job satisfaction, perception of unit and senior management, team work climate, working condition and safety climate domains of safety culture of adult/pediatric non critical care units.
  • Mean score on subscale of stress recognition stands lowest pre and post CUSP and showed a nominal increase from the baseline.
  • These findings are unique as none of the research has reported CUSP successes in adult medical, psychiatric and pediatric non critical settings.
  • CUSP is an efficient model that can be utilized by non critical in-patient units to positively enhance working condition, teamwork climate, job satisfaction, safety climate of their units and to improve the perspective of staff about leadership.
  • Organizations need to track other evidence based interventions to appreciate and improve on stress recognition domain of safety culture.

Implications for Practice



  • Small sample size
  • Convenient sample-----unequal representation from all departments
  • Incomplete data (SD and sample size for unit level scores, responses by staff categories)
  • Inadequate control over confounding variables
  • Long term sustainability of the positive outcomes are not ascertained.
  • CUSP is a bundle intervention, thus, could not determine which intervention works best for which domain of safety culture.

Implications for Research

  • Randomized control trial to establish a cause and effect relationship.
  • Compare CUSP with other interventions that proclaims to improve safety culture.
  • Longitudinal study that evaluates if CUSP is able sustain the safety culture scores.
  • Identify and test interventions other than CUSP to improve the stress recognition domain of safety culture.
  • Aranaz-Andres, J.M., Aibar-Remon, C., Vitaller-Burillo, J., Requena-Puche, J., Terol-Garcia, E., Kelley, E., Gea-Velazquez de Castro, M.T., group E.w., 2009. Impact and preventability of adverse events in Spanish public hospitals: results of the Spanish National Study of Adverse Events (ENEAS). International Journal for Quality in Health Care. 21 (6), 408–414.
  • Ausserhofer, D., Schubert, M., Desmedt, M., et al. (2013). The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: A cross sectional survey. International Journal of Nursing Studies. 50, 240-252.
  • Chaboyer, W., Chamberlain, D., Thalib, L.,& et al. Safety culture in Australian intensive care units. Establishing a baseline for quality improvement. (2013). American Journal of Critical Care. 22(2), 93-102.
  • Christine, E,. Sammer, Kristine, L., et al. (2010). What is patient safety culture? A review of the literature. Journal of Nursing Scholarship. 42(2), 156-165.
  • Department of Health and Human Services (DHHS).(2010). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Retrieved from
  • Hong, A.. L.., Melinda, D. S.., Andrew, S., Bradford, D. , et al. (2013). Decreasing Central-Line–Associated Bloodstream Infections in Connecticut Intensive Care Units. Journal of Health Care Quality. 35(5), 78-87.
  • Mardon, R. E., Khanna, K., Sorra, J., Dyer, N.,& Famolaro, T. (2010). Exploring relationships between hospital patient safety culture and adverse events. Journal of Patient Safety. 6,226-32.
  • Morello, R. T., Lowthian, J. A., Barker, A. L., et al. (2013). Strategies for improving patient safety culture in hospitals: A systemic review. British Medical Journal of Quality and Safety. 22, 11-18
  • Paine, A. L., Rosenstein, B. J., Sexton, J.B., Kent, P., Holzmueller, C. G., & Pronovost, P. J. Assessing and improving safety culture throughout an academic medical center: A prospective cohort study. Quality and Safety of Health Care.19, 547-554. doi:10.1136/qshc.2009.039347
  • Kirwan, M., Mathews, A.,& Scott, A. (2013). The impact of work environment of nurses on patient safety outcomes. A multi-level modeling approach. International Journal of Nursing Studies. 50, 253-263.
  • Pronovost, P. J., Berenholtz, S.M., Goeschel, C., Thom, I., Watson, S. R., Holzmueller, C. G., Lyon, J.S., Lubomski, L.H., Thompson, D. A. et al. (2008). Improving patient safety in intensive care units in Michigan. Journal of Critical Care. 23, 207–221
  • Pronovost, P., Needham, D., Berenholtz, S., et al. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine. 355, 2725-32.
  • Pronovost, P. J., Weast, B., Rosenstein, B., et al. (2005). Implementing and validating a comprehensive unit-based safety program. Journal of Patient Safety. 1, 33-40.
  • Saladino, L., Pickett, L. C., Frush, K., Mall, A.,& Champagne, M.T. (2013). Evaluation of a nurse-led safety program in a critical care unit. Journal of Nursing Care Quaity. . 28(2), 139–146.
  • Sexton, J. B., Helmreich, R. L., Neilands, T. B., Rowan, K., et al. (2006). The safety attitudes questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Services Research. 6(44), 1-10. doi:10.1186/1472-6963-6-44
  • Singer, S., Lin, S. Falwell, A., Gaba, D.,& Baker, L.(2009). Relationship of safety climate and safety performance in hospitals. Health Service Research. 44,399-421
  • Simpson, K.S., Knox, E., Martin,M., George,C.,& Watson, S.R.(2011). Michigan health & hospital association keystone obstetrics: A statewide collaborative for perinatal patient safety in Michigan. The Joint Commission Journal on Quality and Patient Safety. 37(12), 544-552.
  • Timmel, J., Kent, P. S., Holzmueller, C. G, et al. (2010). Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. The Joint Commission Journal of Quality and Patient Safety. 36, 252-60.
  • The Joint Commission (2010). Behaviors That Undermine a Culture of Safety. Applicable Joint Commission Standards: Standard LD.03.01.01. Retrieved from
  • Vigorito, M.C., McNicoll, L., Adams, L.,& Sexton B.(2011). Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. Joint Commission Journal of Quality and Patient Safety. 37,509-14.
  • Wachter, R.M.. (2008). Understanding Patient Safety. McGraw Hill Medical, New York Chicago San Francisco
  • Weaver, S. J., Lubomksi, L. H., Wilson, R. F., et al. (2013). Promoting a culture of safety as a patient safety strategy. A systemic review. Annals of Internal Medicine. 158, 369-374.