CLABSI Supplemental Call Series

The Organizational Embrace of CUSP to Improve Patient Safety

Tuesday, March 202:00pm ET/1:00pm CT

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Session Objectives

• 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 the CUSP teams.

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Today’s Speakers

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

Care ManagementSean Maxwell, Lead Angiography Technician

Upper Chesapeake Health Havre de Grace and Bel Air, Maryland

Jim Hursey, MBA, Sr. VP, COOJudi Webster, RN, BSN, PI Patient Safety

Coordinator

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Holy Cross Hospital

CUSP Beyond the ICU

Holy Cross HospitalSilver Spring, Maryland

Yancy Phillips, MD, MACP, Vice President Quality and Care Management

Sean Maxwell, Lead Angiography Technician

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Today’s Agenda

• A little about us• CUSP Teams as the lever• HCH CUSP Team approach• Interventional radiology CUSP• Resilience• Connecting the dots

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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– 1321 Medical staff and 3062 Employees– FY11 Annual discharges 33,210

• Outpatient registrations 170,317 • Surgeries 13,281• Emergency center 88,121

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HCH Patient Safety Initiatives

• Peri-natal Patient Safety Initiative• Stamp Out Sepsis campaign• Hiring experienced nurses• ICU multi-disciplinary rounds• Mandatory influenza immunization• OR universal protocol• Patient Safety Committee• Root Cause Analysis, FMEA• Fall prevention• Etcetera, Etc, Etc……

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December 2010 AHRQ SurveyHCH 12-10

1591

79%

72%

68%

71%

57%

59%

53%

66%

53%

47%

41%

35%

Teamwork w/n units

Supervisor/Manager expectations

Mngt. support for patient safety

Org learning continuous improvement

Overall perception of patient safety

Feedback and comm about error

Communication openness

Frequency of events reported

Teamwork across units

Staffing

Handoffs & transitions

Nonpunitive response to error

AHRQ Survey on Pt Safety Culture

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12

Dimensions%

Po

sit

ive

Sc

ore

CY08 CY09 CY10 CY11

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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

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Comprehensive Unit-Based Safety Program (CUSP)

• Focus on local processes and “defects of care”• Frontline patient safety leader (PSL)• Area manager• Physician champion• Executive partner

– Frontline staff– Other key personnel (e.g., RT in ICU)

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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, Womens’ Surgery, Oncology, ASD– Maternity, NICU, Peds, Observation

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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

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CUSP Teams

11 CUSP Teams representing 14 units and 68% of

frontline staff

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HCH 12-10 HCH 6-11 > 3%1591 1658

79% 81%

72% 72%

68% 71%

71% 74%

57% 60%

59% 63%

53% 56%

66% 70%

53% 57%

47% 49%

41% 44%

35% 37%

Teamwork w /n units

Supervisor/Manager expectations

Mngt. support for patient safety

Org learning continuous improvement

Overall perception of patient safety

Feedback and comm about error

Communication openness

Frequency of events reported

Teamwork across units

Staffing

Handoffs & transitions

Nonpunitive response to error

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CUSP Team Activities

• Team meets 1-2 times per month• Separate Executive Rounds with 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 PSL• CUSP All Teams Meeting

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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?

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Directed Defects Work

• Hand Hygiene– One hour per month “secret shopper” from each

PSL for 3 months• CLABSI—critical care units• CAUTI—med/surg units• CLABSI/VAP/CAUTI defects tool--ICUs

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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

Patient Safety Leader Hours Dedicated to CUSP Teams

45.6

164.9

0

100

200

300

400

500

600

Q1FY12 Q2FY12 Q3FY12 Q4FY12

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CUSP All Teams Meeting

• Bi-monthly at two different times and days• PSLs, managers and physicians• Review tools and reports• Review protected time use• Share experiences and barriers

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Interventional Radiology CUSP

• Medication errors– Emphasize double verification– Direct observation– High alerts meds JIT

• Outdated devices– Inventory label alert– Double confirmation

• Consents• Protected Time

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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

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Focusing Our Organizational Efforts

• Key Outcomes– Actively Engaged Staff– Overall Perception of Safety

• Key Drivers– Communication Openness– Staff Burnout

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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

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Resilience• Is an ability to recover from or adjust easily to

misfortune or change• Is the ability to become strong, healthy, or successful

again after something bad happens • 4 Fs--Friends, Family, Faith, Fitness• Resilience Resource Team

– to identify, organize and communicate about existing resources to combat burnout

– to develop new initiatives that increase resilience.

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Connecting the Dots

Resilience

Actively Engaged Staff

Open Communication

Staff Retention

Patient Safety

CUSP Teams

Just Culture

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Upper Chesapeake Health, Maryland

Jim Hursey, MBA, Sr. VP, COOJudi Webster, RN, BSN, PI Patient Safety

Coordinator

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Upper Chesapeake HealthMaryland

2 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

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Senior Leadership Commitment

• Establish the Culture of Safety Senior Leadership support is the key to success Set Expectations for Leaders and Team Members

Patient Safety incorporated into the Culture of Excellence philosophy and Strategic Plan Starts in Orientation of New Team Members

• Jose King video for all TM• Science of Safety video for clinical and Security

TM Insure Administrative Polices are in place to support a

Culture of Safety and Just Culture Stop the Line Policy 28

Senior Leadership Commitment

Facilitate Improvements by providing resources Support non-productive 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 non-threatening

environment Participate in Patient Safety Walkabouts and

Collaborative Executive Rounding Listen to TMs

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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 Culture of Safety Survey completed in December 2009

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Our Journey

CUSP:CLABSI Collaborative Project started November 2010, calling for monthly rounds in ICU’s. Used Staff Safety Assessment as the basis

for initial talking points for Sr. Leadership to create a less threatening environment.

Open forum for discussion of concerns

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Flexibility is a Necessity

Began by scheduling 1 hour in each ICU, at each facility, every month Difficult for Sr. 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, Leaders running to next meeting – very stressful for all

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Current Process

Monthly ICU rounds 30 minute sessions, can accomplish everything in about 20 minutes

on the ICU’s 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 33

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

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Sample Walkabout Grid

Patient Safety Issues Primary Topic Sub-Topic Date Identified

Contact VP Notes/Follow-up Target Date

Patient Safety Issues Primary Topic Sub-Topic Date Identified

Contact VP Notes/Follow-up Closed Date

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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

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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!

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Your Feedback is Important!

https://www.surveymonkey.com/s/Z6FJ28T

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Questions

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