Welcome to the

NE QIN-QIO Webinar!

Our presentation will begin shortly.

Please dial in to the audio line by calling

888-830-8905

Passcode: 519600

Lynn McNicoll, MD Hospital and Nursing Home Consultant

Healthcentric Advisors of Rhode Island

Associate Professor of Medicine

Alpert Medical School of Brown University

Division of Geriatrics and Palliative

Medicine 2

The Motivation…

3

Disclosures

None

4

Acknowledgements

AHRQ CUSP Toolkit

http://www.ahrq.gov/professionals/quality-patient-safety/cusp/index.html

Armstrong Institute for Patient Safety and Quality faculty slides

www.onthecuspstophai.org

TeamStepps Department of Defense

http://teamstepps.ahrq.gov/

5

Learning Objectives

Participants will be able to:

1. Explain CUSP impact on safety

2. List CUSP Components

3. Describe how a regional organization (NE QIN-QIO) can support Hospital CUSP efforts

6

Expansion of Research in Safety Culture

7

Interventions to Promote Safety Culture: Systematic Review

3679 articles 162 full review33 included

8 = multi-faceted interventions

20 included team-training, communication tools

8 included executive walkrounds

29 significantly improved safety culture survey scores or outcomes

Limitations: strength of evidence was low and most studies are pre-post evaluations of low to moderate quality

“Evidence ‘suggests’ that interventions can improve perceptions of safety culture and potentially reduce patient harm”

8 Weaver, et al Annals of Int Med 2013: 158(5);369

HAI’s and CUSP

CUSP has been traditionally implemented in ICU

Literature is most supportive of ICU and specifically CLA-BSI

On the CUSP: Stop BSI

On the CUSP: Stop CAUTI

HAI’s are not limited to ICU (especially SSI, CAUTI, CLA-BSI), i.e. HAI occur on surgical and medical units throughout the hospital

CUSP is one strategy to help create a culture of safety to help prevent HAI’s

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Has your hospital participated in ANY of the following CUSP initiatives?

a) ICU Collaborative

b) On the CUSP: Stop BSI

c) On the CUSP: Stop CAUTI

d) 2 or more of the above

e) None of the above

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HAIs: RI vs National SIR (Standardized Infection Ratio)

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State 2012 vs

2013

2013 State vs 2013 Nat’l

2013 State vs Nat’l

Baseline

2013 State SIR

2013 Nat’l SIR

CLABSI 8% 25% 33% 0.67 0.54

CAUTI 6% 20% 27% 1.27 1.06

SSI hyst 59% 21% 32% 0.68 0.86

SSI colon 4 43% 32% 1.32 0.92

MRSA bact n/a 1% 10% 0.91 0.92

C Diff n/a 31% 18% 1.18 0.9

What are the foundational elements of CUSP?

Focus on systems, not individuals

Value communication and teamwork

Emphasize infrastructure and support

Accept responsibility for the systems in which we work

Recognize that culture is local

Respect transparency

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The 4E’s Principle

1. Engage with stories, show baseline and benchmarking data

2. Educate staff on evidence

3. Execute

Standardize: foley removal protocol/order set

Create independent checks: Create BSI checklist

Empower any providers to ‘stop the line’

Learn from mistakes

4. Evaluate

Provide updated and accurate results

Do analysis of deficits

13

How does CUSP Contribute to a Culture of Safety?

Designed to improve safety culture and help staff learn from mistakes

Integrates safety practices into the daily work of a unit or clinical area

Provides a scalable intervention

Can be implemented throughout the hospital or organization

Draws wisdom from frontline staff to fix hazards

Creates the forum necessary to speak up

Empowers staff to improve safety culture

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What is CUSP?

Comprehensive Unit-Based Safety Program

Steps:

1. Evaluate your culture

2. Understanding the Science of Safety

3. Assembling a team

4. Implement teamwork and communication

5. Identify and learn from defects

6. Engage senior executive members

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CUSP Step 1: Evaluate your culture

Tools to help evaluate the domains of a culture of safety – assesses safety CLIMATE – shared perception or attitude about the norms, policies, and procedures related to patient safety in a snapshot in time

SAQ – Safety Attitude’s Questionnaire

Most are using AHRQ Hospital Survey on Patient Safety Culture

Can measure, create action plan for addressing weak areas, then re-measure (usually annually or biannually)

RI ICU Collaborative Example …

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RI State Aggregate SAQ Domain Improvement Trends

Ave

rage

Pe

rce

nt P

erc

ep

tio

n

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Is your hospital currently administering any type of Safety Climate Survey?

a) SAQ: Safety Attitudes Questionnaire

b) AHRQ Hospital Survey on Patient Safety Culture

c) Home grown

d) None

e) Do not know

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CUSP Step 2: Understanding the Science of Safety

Science of safety video on website is accessible and quite inspiring

www.onthecuspstophai.org

www.safercare.net

Josie King story/video/book as told by

Sorrel King

Standardize, create checklists

Eliminate steps

Learn when things go wrong

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CUSP Step 2: Train Staff in the Science of Safety

Science of Safety Training principles:

Understand that safety is a property of systems

Identify principles of safe design (standardize, create independent checks, learn from mistakes)

Understand that teams make wise decisions with diverse and independent input – avoid blame culture

Recognize that principles of safe design apply to both technical and team work – speaking up when concerns arise and listening when others speak up!

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CUSP Step 3: Establish a Team

Unit Level

Mostly engaged and passionate members

Consider including biggest critics (with the goal of converting them to your cause eventually)

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Who is essential to the CUSP Team?

CUSP

Frontline Staff

Senior Hospital Executive

CUSP Coach

Physician Champion

CUSP Unit Champion

Nurse Manager

Patient Safety Coordinator/ Patient Safety

Officer

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CUSP Step 4: Implement Teamwork Tools and Communication

Tools to improve:

1. Daily Goals Checklist

2. Morning Briefing

3. Observing Rounds

4. Shadowing another Profession

5. Culture debriefing Tool

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1. Daily Goals

• What needs to be done for the patient to be discharged?

• What is the patients greatest safety risk?

• What can we do to reduce the risk?

• Can any tubes, lines, or drains be removed?

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1. Daily Goals Form: Example

AM shift (7am) PM shift (7pm) **Note Changes

from AM**

Saf

ety

What needs to be done for patient to be discharged from the ICU?

Patient’s greatest safety risk? How can we decrease risk?

What events or deviations need to be reported? ICUSRS issues?

Pat

ien

t C

are Pain Mgt / Sedation

(held to follow commands?) Pain goal ____/ 10 w/

Cardiac Review EKGs

HR Goal_______ at goal

ß Block_________

Volume status Net goal for midnight

Net even Net positive Net neg:____ w/_______ Pt determined

Pulmonary: Ventilator: (vent bundle:

HOB elevated), RTW/Weaning)

OOB Pulm toilet Ambulation Maintain current support Wean as tol Mechanics q am FIO2 <_____ PEEP____ PS / Trach trial___h

SIRS/Infection/Sepsis Evaluation SIRS Criteria Temp > 38° C or < 36 ° C HR > 90 BPM RR > 20 b/min or PaCO2 < 32 torr WBC > 12K < 4K or > 10% bands

no current SIRS / Sepsis issues Known infection: PAN Cx Bld x2 Urine Sputum Other ABx changes; D/C AG Levels: Sepsis Bundle

Can catheters/tubes be removed?

Y N

GI / Nutrition / Bowel regimen (TPN line, NDT, PEG needed?)

TPN TF NPO

Is this patient receiving DVT/PUD prophylaxis?

DVT: Hep q8 / q12 / gtt PUD: PPI TEDS/SCDs H2B LMWH

Anticipated LOS > 2 days: TGC 3 days: fluconazole PO, KCl SS

TGC Fluc KCl N/A

Can any meds be discontinued, converted to PO, adjusted?

N/A D/C: PO: Renal: Liver:

To

Do

:

Tests / Procedures today N/A Scheduled labs N/A

AM lab needed CXR?

CMP BMP H8 Coags ABG Lactate Core 4 CXR Wed: Transferrin Iron Prealb 24h urine

Consultations Y N

Dis

po

siti

on

Is the primary service up-to-date?

Y N

Has the family been updated? Social issues addressed (LT care, palliative care)

Y N Y N N/A

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2. AM Briefing

• Have a morning meeting with charge nurse and physician champion/attending

• Discuss work for the day

– What happened during the evening?

– Who is being admitted and discharged today?

– What are potential risks during the day, how can we reduce these risks?

– Patient scheduling? Equipment problems? Staffing? Provider Skill mix?

–Assign person to follow-up 26

3. Shadowing

• Follow another type of clinician doing their job for 2-4 hours

• Discuss with the team what they will do differently now that they walked in another person’s shoes

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3. Shadowing Process Questionnaire

Were any healthcare providers difficult to approach?

Did one provider get approached more often for patients issues? Why?

Did you observe an error in transcription of orders?

Did you observe an error in the interpretation or delivery of an order?

Were patient problems identified quickly?

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4. Culture Debriefing Tool

In RI, we referred to this as SAQ Action Plan

Pick an area that is poor from your safety climate survey

Convene a group to discuss the item and develop a plan on how to address

Use debriefing tool to develop improvement actions

Use active listening skills to guide the feedback but do not run the meeting

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4. Culture Debriefing Tool: Discussion Form

Choose a statement to be discussed from the item

1. What does this statement mean to you?

2. How accurately does the unit score reflect your experience on this unit?

3. How would it look (i.e. what behaviors or processes would we see) on this unit if 100% of caregivers responded agree strongly with this item?

4. Identify at least one actionable idea to improve unit results in this area

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RI Results- % change in SAQ Scores 2007 to 2008

-10

-5

0

5

10

15

20

25

30

Teamw

ork

Safety

Clim

ate

Job Satis

Stress R

ec

Work

ing C

ond

Perc o

f Mgm

t

Units withPlans

UnitswithoutPlans

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RI Results- % change in BSI and VAP 2007 to 2008

-16

-14

-12

-10

-8

-6

-4

-2

0

2

4

6

CLA-BSI VAP

Units with

SAQAP

Units

without

SAQAP

Vigorito MC et al. Improving safety culture results in Rhode Island ICUs: lessons learned from the

development of action-oriented plans. Joint Comm J on Qual & Pat Safety. 2011;37(11):509-14 32

CUSP Step 5: Identify Defects

Defect = anything the you don’t want to happen again!

Staff Safety Assessment- all staff are asked to identify:

How will the next patient will be harmed?

What can we do to prevent that harm?

Use defects identified in the event reporting system

Use sentinel events

Near misses or ‘good catches’

Use results from your culture assessment scores and debreifings

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CUSP Step 5: Learn from Defects Tool

1. What happened?

2. Why did it happen? Which factors contributed? 1. Patient factors (elderly, language, refusal)

2. Task (protocol, inaccurate results)

3. Provider (fatigue, personal issues)

4. Team (orders clearly communicated)

5. Training (follow protocol, lack of supervision)

6. IT (computer error/malfunction)

7. Local (insufficient staffing, skill mix, overloaded)

8. Institutional (financial resources)

3. How will you reduce the likelihood of this defect happening again?

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Rank Order of Error Reduction Strategies

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Forcing functions and constraints

Automation and computerization

Standardization and protocols

Checklists and double check systems

Rules and policies

Education / Information

Be more careful, be vigilant

Eliminate

Replace

Facilitate

Replace

Facilitate

Facilitate

Facilitate

Eliminate

Replace

Facilitate

Strength of Interventions Adapted from John Gosbee, MD, MS Human Factors Engineering

Weaker Actions Intermediate Actions Stronger Actions

Double Check Checklists/ Cognitive Aid Architectural/physical plant

changes

Warnings and labels Increased Staffing/Reduce

workload

Tangible involvement and

action by leadership in

support of patient safety

New procedure,

memorandum or policy

Redundancy Simplify the

process/remove

unnecessary steps

Training and/or education Enhance Communication

(read-back, SBAR etc.)

Standardize equipment

and/ or process of care

map

Additional Study/analysis Software

enhancement/modifications

New device usability

testing before purchasing

Eliminate lookalike and

sound-alikes

Engineering Control of

interlock (forcing

functions)

Eliminate/reduce

distractions

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CUSP Step 6: Executive Partnership

Goal = bridge the gap between senior management and frontline staff

The role of the senior executive is one of advocacy and action in support of the unit’s safety efforts and to work to obtain needed resources for improvement efforts

The executive is encouraged to discuss safety issues, help to remove barriers, and implement improvement efforts

Brief frontline providers prior to visit

Affords opportunity to solicit staff input on errors, near misses and other safety issues

Identify, manage and track improvement projects

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Executive WalkRounds Questions

Can you think of any incidents or adverse events that happened in the past few days that have resulted in prolonged hospitalization for a patient?

Can you think of patients we have harmed as a result of problems with how we deliver care?

What could leadership do to support you in providing safe patient care?

What changes could be made in this unit to promote patient safety more consistently?

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CUSP Lessons Learned

Culture is local Implement in a few units, adapt and spread Include frontline staff on improvement team

Not linear process Iterative cycles Takes time to improve culture

Couple with clinical focus No success improving culture alone CUSP alone viewed as ‘soft’ Lubricant for clinical change

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Seven Spreadly Sins

1. Start with large projects

2. Find one person willing to do it all

3. Expect vigilance and hard work to solve a problem

4. If a pilot project works then spread it unchanged

5. Require the person and team who drove the pilot project to be responsible for system-wide spread

6. Look at process and outcome measures quarterly

7. Expect marked improvement in outcomes early on without attention to process reliability

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How can the NE QIN-QIO support Hospital CUSP efforts?

Use us (and each other) as a resource

Many members have done versions of CUSP or TeamStepps and we can learn from each other

NE QIN-QIO will provide reports on HAI data quarterly

We will continue to provide regional webinars on HAI, let us know which topic area you would like to hear about

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Summary

CUSP components are straightforward but difficult to implement in non-ICU settings where the team is not well defined (especially physician members)

Introducing the Science of Safety and some tools (one at a time) is doable

Engage executive champion early and often

Improving the Culture of Safety is an ongoing challenge

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a) Connecticut (CT)

b) Maine (ME)

c) Massachusetts (MA)

d) New Hampshire (NH)

e) Rhode Island (RI)

f) Vermont (VT)

g) Other

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What state are you from?

a) One (1)

b) Two (2)

c) Three (3)

d) Four (4)

e) Five (5)

f) Six (6)

g) Seven (7)

h) Eight (8)

i) Nine (9)

j) Ten or More (10+)

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How many people are watching on your computer or login information?

Questions?

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References Andrews LB, Stocking C. An alternative strategy for studying adverse events in medical care. The Lancet. 1997;349(9048):309-

313.

Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Critical Care Medicine. 1995;23(2):294-300.

Leape LL, Cullen DJ, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282(3):267-270.

Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Eff Clin Pract. 2001;4:199-206.

Tucker AL, Edmondson AC. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change. California Management Review, 2003 ;45(2):55-72.

Reason J. Human Error. Cambridge, UK: Cambridge Univ Pr; 1990.

Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv. 2001;27:522-32.

Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006;32(2):102-108.

Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med. 2004;140(12):1025-1033.

Vincent C. Understanding and responding to adverse events. New Eng J Med. 2003;348:1051-6.

Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:685-87.

Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance Morbidity and Mortality Conferences. Am J Med Qual. 2009;24(3):192-5.

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