april 28 , 2014 and april 30, 2014
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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CUSP for Safe Surgery (SUSP)Kickoff Webinar
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April 28, 2014 and April 30, 2014
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Some quick administrative announcements
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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.
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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
“”
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SUSP Kickoff Agenda
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Introductions
SUSP Project Overview
Building your SUSP Team
Intro to Building and Measuring Safety Culture
Current Team Experiences
Next Steps
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INTRODUCTIONS
Meet the SUSP National Project Team
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Peter Pronovost, MD, PhD, FCCM
Principal Investigator
Cliff Ko, MD, MS, MSHA, FACSPrincipal Investigator
Charles Bosk, PhDPrincipal Investigator
Ethnographer
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Deb Hobson, RNState Coach
Content Expert
Julius Pham, MD, PhDState Coach
Content Expert
Liza Wick, MDState Coach
Content Expert
Bradford Winters, MDState Coach
Content Expert
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Mike Rosen, PhDState Coach
Content Expert
Lisa Lubomski, PhDState Coach
Content Expert
Sallie Weaver, PhDState Coach
Content Expert
Sean Berenholtz, MD, MHS, FCCM
State CoachContent Expert
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Tricia Francis, MA, MS, PMPSUSP Project Manager
Kathryn Taylor, RN, MPHSUSP Program Manager
Kristina Weeks, MHSCo-Investigator
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Cathy Van De Ruit, PhDEthnographer
Ksenia Gorbenko, PhD, MA
Ethnographer
Jeremiah BowmanAmerican College of
Surgeons
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Erin Hanahan, MPHSUSP Senior Research
Coordinator
Mary Twomley, MSSUSP Senior Research
Coordinator
Laura Vail, MSSUSP IT Specialist
Nasir Ismail, MSSUSP Safety Culture
Coordinator
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Poll – Who is on the call?
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What is your role in your clinical area?Surgeon
Quality improvement practitioner
Infection preventionist
OR Nurse
OR technician
Anesthesiologist
OR manager
Other
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SUSP PROJECT OVERVIEWSEAN BERENHOLTZ, MD, MHS, FCCM
We have embarked on a unique journey.
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Learning Objectives
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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
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Why is Your SUSP Work Important?1
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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
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Surgical Care Improvement Project (SCIP)2
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Respond in the chat.
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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?
Engagement Questions
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SUSP is CUSP for Safe Surgery
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What is SUSP?
National improvement effort
Designed to reduce surgical site infections (SSI) and other surgical complications.
CUSP is the acronym for “Comprehensive Unit-based safety program”
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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
What is SUSP?
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Agency for Healthcare Research and Quality
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AHRQ-funded projectIndividual 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
What is SUSP?
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SUSP Leverages Leaders In The Field
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SUSP Enrollment by Coordinating Entity
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International HospitalsLocated in Canada and UK
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SUSP Enrollment by Coordinating Entity
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Coordinating Entity Qty
Coordinating Entity Qty
Armstrong Institute 44 Maryland Hospital Association 19
Arkansas Hospital Association 10 Massachusetts Hospital
Association 8California Hospital Association 2 Michigan Health & Hospital
Assoc 46
Colorado Hospital Association 8 New Jersey Hospital Association 14
Connecticut Hospital Association 7 North Carolina Quality Center 3
Florida Hospital Association 11 Nevada Hospital Association 5Georgia Hospital Association 16 Premier Healthcare Alliance 10Hawaii Safer Care SUSP Collaborative 14 Tennessee Hospital
Association 10Iowa Healthcare Collaborative 13 VHA 14
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SUSP Enrollment by Cohort
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Cohort 1
Cohort 2
Cohort 3
Cohort 4
Cohort 5
0 50 100 150 200 250 300
10
113
161
203
256
Cumulative enrollment
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Our Shared Project Goals
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To achieve significant reductions in surgical site infection and surgical complication rates
To achieve significant improvements in safety culture
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Key Concepts: Adaptive And Technical Work
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TechnicalWork
Adaptive WorkSweet
Spot
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Technical Work Adaptive WorkProcedural components of work, like performing skin prep
The ‘intangible’ components of work, like ensuring an OR team holds each other accountable for quality skin prep
Work that we know we ‘should’ do, like letting skin prep dry before incision
Work that shapes the attitudes, beliefs, and values of clinicians, so they consistently perform tasks the way they know they ‘should’
Work that lends itself to checklists or protocols
Culture change is not a checklist
Key Concepts: Technical and Adaptive Work
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Intervention Requires Technical & Adaptive
1995
1997
1999
2001
2003
2005
2007
2009
2011
0
40
80
120
160
0 2 32640
5660675350
907594
116149
93
152
Reviewed by The Joint Commis-sion
Regardless of procedure mag-nitude
Num
ber
of E
vent
s Re
view
ed b
y TJ
C
A. Sentinel Event Alert: Wrong-sided surgery Aug 98
B. Sentinel Event Alert: Follow-up review of wrong-sided surgery Dec 01
C. Wrong Site Surgery Summit I Jan 03
D. Universal Protocol 2004
E. Wrong Site Surgery Summit II Feb 07
F. Revised Wrong Site Surgery Definition Jun 10
AB
CD
EF
Despite years of technical intervention, rates rose
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CUSP is a model to guide adaptive work3
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1. Educate staff on the science of safety
2. Identify defects
3. Partner with a Senior Executive
4. Learn from defects
5. Improve teamwork and communication
Comprehensive Unit-based Safety Program (CUSP)
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How is SUSP different?
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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
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Building on Previous State Level Success
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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
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…And National Level Highlights
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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.
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Hospital-acquired Infection Rates Drop
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Safety Climate Teamwork Climate0
10
20
30
40
50
60
70
80
90
100
84% 82%
23% 22%
2004 2007
“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
While Safety Culture Increases
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Colorectal NSQIP SSI Rate at Hopkins9
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This Improvement Model Works In The OR
Q3 09 Q4 09 Q1 10 Q2 10 Q3 10 Q4 10 Q1 11 Q2 11 Q3 11 Q4 11 Q1 12 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 130%
5%
10%
15%
20%
25%
30%
35%
40%
45%
42%
17%
29%
26%
16%
20%
10%
18%
21%
24%
15%
21%
13%
18%
12%
5%
15%
2%
Time Period
SSI R
ate
(%)
CUSP kickoffAntibiotic deficienciesaddressed
Pre-op warmingEnhanced sterile techniqueIntervention checklist Briefing/Debriefing
Mechanical bowel prep with oral antibiotics
SSI InvestigationBowel Prep KitsEHR support
Skin prep protocolPre-op wash clothes
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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.
Problem
Barriers
Intervention
Impact
Case Study: Laparoscopic GI Surgery Trays
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137 instruments 54 instruments
Case Study: Laparoscopic GI Surgery Trays
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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
$537,000 annual savings on antibiotic irrigation WITH surgeon buy-in
Problem
Barriers
Intervention
Impact
Case Study: Antibiotic Irrigation
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Case Study: Antibiotic Irrigation
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SUSP Project Management Guide
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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?
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SUSP Project Structure
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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)
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SUSP Project Structure
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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)
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SUSP Project Structure
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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
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Polling Question
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How ready is your organization to enable frontline participation in improvement work and address frontline patient safety priorities?
– Totally ready
– Getting ready
– Not ready at all
– Not sure
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References
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1. 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.
2. 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.
3. The Joint Commission, Sentinel Event Data. http://www.jointcommission.org/assets/1/18/Event_Type_Year_1995-2011.pdf;29. Accessed August 8, 2013.
4. 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.
5. 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.
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References
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6. 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 Hosp Epidemiol. 2011; 32(4): 305–314.
7. 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.
8. 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.
9. Wick et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. J Am Coll Surg. 2012; 215 (2).
10. The Joint Commission. J Qual Patient Saf. 2010;36:252-6http://www.ahrq.gov/cusptoolkit/
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BUILDING YOUR SUSP TEAMMIKE ROSEN, PHD
Who is in the room with you?
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Polling Question
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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
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Learning Objectives
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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
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Kevin Driscoll CRNACRNA Lead
Deb Hobson RN“Coach”
Tracie Cometa RNLead RN
Mary Grace Hensel RNManager OR
Sean Berenholtz MDAnesthesia Lead
Lucy Mitchell RNNSQIP SCR
Elizabeth Wick MDSurgery Lead
Renee Demski MBASenior Director QualityJohns Hopkins Medicine
Steph Mullens CSTLead Tech
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Perioperative SUSP Team Members
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Essential Team MembersSurgeonsAnesthesiologistsCRNAsCirculating nursesScrub nurses / OR techsPerioperative nursesExecutive partnerNurse leaders
Enhancing Team MembersPhysician assistantsNurse educatorsAnesthesia assistantsInfection preventionistsOR directorsPatient safety officersChief quality officersAncillary staff
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The SUSP Team
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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
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SUSP Team Logistics
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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
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Enter response in the chat.
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How can you protect 2 – 4 hours of time per week for your SUSP team leaders?
Polling Question
Activity: Brainstorm how to prioritize the need for protected time.
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SUSP Teams’ Group Processes
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Effective Group
Processes
Norms
Role Clarity
Effective Team Communication
Conflict Resolution
Education and
Engagement
Leadership Buy-in and
Support
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Role of Senior Executive Partner
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• 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
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Finding an Executive Partner
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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
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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
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Engage Surgeons on the SUSP Team
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Identify surgeon leaders
Explain this role
Formalize plan for
communications
Listen to surgeon concerns
Develop plans to address concerns
Reward surgeon leaders
Determine best vehicle for
communication
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Practical Tips for Scheduling SUSP Meetings
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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
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You Have Access To Some Helpful Tools
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Team Roles and Responsibilities Form
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Additional CUSP Tools
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Next Steps
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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
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Polling Question
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Do you think that your team can influence your organization to enable frontline participation in improvement work and 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
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AN INTRODUCTION TO BUILDING AND MEASURING SAFETY CULTURESALLIE WEAVER, PHD
The “adaptive” glue that helps bond safe teams
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Learning Objectives
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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
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What is Safety Culture?
Image source: Marysia Tomaszewska, August 8, 2012, used under a Creative Commons License
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Perceived priority of safety relative to other goalsCulture 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.
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Core Aspects of a Safety Culture1
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Safety Culture Is Related To Outcomes2,3,4,5,6,7,8
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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
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Why Safety Culture Matters9,10,11,12
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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
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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 be measured 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
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Example: HSOPS Questions & Composite Scores
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10 Composite Scores (“Dimensions”)
No. of Questions
Example Question
1. Supervisor/manager expectations & actions promoting patient safety 4 B1. My supervisor/manager seriously considers
staff suggestions for improving patient safety.
2. Organizational learning-continuous improvement 3 A9. Mistakes have led to positive changes here.
3. Teamwork within unit 4 A1. People support one another in this unit.
4. Communication openness 3 C4. Staff feel free to question the decisions or actions of those with more authority.
5. Feedback & communication about error 3 C1. We are given feedback about changes put into place based on event reports.
6. Nonpunitive response to error 3 A8. Staff feel like their mistakes are held against them. (negatively worded)
7. Staffing 4 A2. We have enough staff to handle the workload.
8. Hospital management support for patient safety 3 F8. The actions of hospital management show that
patient safety is a top priority.
9. Teamwork across hospital units 4 F4. There is good cooperation among hospital units that need to work together.
10. Hospital handoffs & transitions 4 F5.Important patient care information is often lost during shift changes. (negatively worded)
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4 Outcome Variables No. of Questions
Example Question
1. Overall perceptions of safety 4 A15. Patient safety is never sacrificed to get more work done.
2. Frequency of event reporting 3 D1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?
3. Patient safety grade (of hospital unit)
1 E1. Please give your work area/unit in this hospital an overall grade on patient safety.
4. Number of events reported in the last 12 months
1 G1. In the past 12 months, how many event reports have you filled out and submitted?
Example: HSOPS Questions & Composite Scores
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Polling Question
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Has your hospital collected data about your work area’s culture of safety in the previous 12 months? – Yes
– No
– Not sure
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Have Existing HSOPS Data?
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Have you collected data about the safety culture in the last twelve months? If yes:
When was this data collected and how? (Online or Paper Survey, In-person Interview)
Who has access to this data?
What aspects of culture were measured and what data was captured?
Where are copies of the raw data (spreadsheets) and reports (PDF file with charts and graphs)?
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Key Role of HSOPS Survey Coordinator
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
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Tip: SUSP Online Portal can be found at https://armstrongresearch.hopkinsmedicine.org/susp.aspx
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Next Steps
Complete the SUSP Portal Registration Form, if you have not already done soIdentify 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 monthsCohort 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
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References
1. Schein E. Organizational culture and leadership, 4th edition. San Francisco, CA: Jossey-Bass. 2010.
2. 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.
3. MacDavitt K, Chou SS, Stone PW. Organizational climate and health care outcomes. Jt Comm J Qual Patient Saf. 2007 Nov;33(11 Suppl):45-56.
4. Mardon RE, 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.
5. 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.
6. Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring Relationships Between Patient Safety Culture and Patients' Assessments of Hospital Care. J Patient Saf. 2012 Jul 10. [Epub ahead of print].
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References
7. 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.
8. 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.
9. 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 Qual Saf. 2011 Jan;20(1):102-7.
10. Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf. 2012 Jul 31. [Epub ahead of print]
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References
11. 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.
12. 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.
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John Muir Medical Center
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John Muir Medical Center SUSP Experience Video
SUSP Team Experience
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NEXT STEPSERIN HANAHAN, MPHMARY TWOMLEY, MS
We’re in this together.
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Polling Question
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What percentage of organizational change efforts fail?- 0 - 20%- 21 - 40%- 41 - 60%- 61 - 80%- 81 - 100%
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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.
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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 scenario look like?
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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?
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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?
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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.
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Premortem Summary
1. Two years out, what does the worst case scenario look like?
2. What could have caused your project to fail?
3. What specific actions can you take to avoid or manage these issues?
4. Review and anticipate potential problems throughout the project.
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SUSP Portal Project Planning Resources
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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
DRAFT – final pending AHRQ approval
WRAP UP
How will the SUSP Project look in your hospital?
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Summary of Next Steps
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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
DRAFT – final pending AHRQ approval
What’s Next?
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Remember, We Are Here To Help!
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Ask questions during coaching calls
Contact the SUSP helpdesk at [email protected]
DRAFT – final pending AHRQ approval
Kickoff Webinar Evaluation
https://www.surveymonkey.com/s/cohort_5_onboarding
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Your feedback is very important to us.
Please take the time to help us understand how to best support you.
DRAFT – final pending AHRQ approval