Comprehensive Unit-based Safety Program(CUSP)
Teré Dickson, MD, MPHHAI Webinar April 9, 2012
CMS Leads a national healthcare quality improvement program,
implemented locally by an independent network of QIOs in each state and territory.
IPRO The federally funded Medicare Quality Improvement
Organization (QIO) for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS).
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The QIO Program Largest federal program dedicated to improving health
quality at the local level,
Trustworthy partners for the continual improvement of healthcare for all Americans,
Focuses on three broad aims:
Better patient care,
Better population health,
Lower healthcare costs through improvement.
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As the QIO for New York State, IPRO works to achieve the goals of the national QIO program by Convening communities of providers, practitioners and
patients across the state to:
Share knowledge,
Spread best practices,
Achieve rapid, wide-scale improvements in patient care.
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The QIO Program supports patients by: Providing information to help you better manage your
own healthcare,
Reviewing quality of care complaints,
Working with local healthcare providers to make healthcare safer and “patient-centered,”
Listening to you and learning from your experiences,
Helping to remove roadblocks between you and better healthcare.
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The QIO Program supports providers by: Managing and sharing evidence-based best practices,
knowledge and tools for improving health quality, efficiency and value.
Serving as a change agent for rapid, widespread and significant improvements that contribute to broader national healthcare goals.
Facilitating collaborative learning and action that results in better, more patient-centered care.
Encouraging beneficiaries to take a more active role in their own healthcare.
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QIO Program Priorities 2011-2014
Beneficiary- and Family-Centered Care
Improving Individual Patient Care by Reducing Healthcare-Associated Infections in Hospitals
Healthcare-Acquired Conditions in Nursing Homes
Adverse Drug Event
and through Quality Reporting
Integrating Care for Populations and Communities
Improving Health for Populations and Communities
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Today’s Webinar:CUSP Town Hall Meeting
A town hall meeting is an informal public meeting which gives the members of a community an opportunity to get together to discuss emerging issues and to voice concerns and preferences for their community.
- www.wisegeek.com
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Interact with us!
Operator assisted call
Chat box To the group
To the moderator
When you respond or comment, please say your name and hospital.
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Special Guests – St. John’s Episcopal Hospital
St. John’s Episcopal Hospital is the only full service community hospital serving the entire Rockaway and the Five Towns communities providing general adult medical surgical services, pediatrics, obstetrics and psychiatric services. Initiated CUSP in January 2010
Gail Johnson
Nancy Traver
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Poll Question 1
My hospital has started using CUSP to address CLABSIs and CAUTIs. Yes
No
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Poll Question 2
My hospital has considered using CUSP, but either decided against it or doesn’t know how to get started. Yes
No
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Poll Question 3
My hospital has an alternative to CUSP in place, such as the use of brainstorming teams, multidisciplinary patient safety rounds with hospital administration, feedback to unit staff on infection rates and targets, educational sessions for unit staff, and/or application of root cause analysis to investigate infections. Yes
No
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Principles of CUSP
Understand system determines performance and results.
Use strategies to improve system performance.
Apply strategies to both technical work and team work.
Recognize teams make wise decisions with diverse and independent input.
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Five Steps of CUSP
1. Educate staff on the science of safety
2. Identify defects
3. Assign executive to adopt unit
4. Learn from one defect per quarter
5. Implement teamwork tools
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The 4E’s to CUSP Success
Engage Storytelling, Press releases, Share data
Educate staff on evidence
Execute Standardize
Create independent checks
Empower nursing
Learn from mistakes
Evaluate Performance and progress feedback
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Keep It Simple
CUSP Learn from 1 defect per desired time period Collaboration Consolidation Sustainability
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CUSP In-depth
On The CUSP: Stop HAIhttp://www.onthecuspstophai.org/
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The St. John’s Episcopal Hospital CUSP Experience
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Choosing CUSP
Driving Forces High CLABSI Rate
MICU: 2.6/1000 device days in 2010 with a national mean of 1.9
Hospital Administrator - Sharon Behar, VP for Regulatory Affairs
HANYS and national On the CUSP initiative
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Pre-CUSP Activities
Web Conferences
Team Formation Administrative Champion
Infection Control Committee Chairman
Physician Champion
Nursing Champion (VP of Patient Care Services)
Infection Preventionist
Data Collection
AHRQ Hospital Survey on Patient Safety
Trained staff on Science of Safety
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CUSP Processes for CLABSI Prevention
Removal of the defects that lead to central line related bacteremia
Understanding the complexity involved to creating a plan to reduce errors
Putting all equipment needed for insertion in one place and/or pkg
Residents must notify nurse who will assist with insertion Insertion checklist to empower nurses to document
deviations Observing Rounds AM and PM Briefing Daily Goals Checklist
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CUSP Intervention - Peer Review
Developed the peer review form to assess the compliance with all strategies and bundles. The night shift monitors
the day shift on care for patients with lines and vice versa.
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CUSP Results
MICU had a rate of 2.6/1000 device days in 2010 with a national mean of 1.9 2011: the rate had dropped to 1.5 below the national mean
of 1.6
Feedback to Staff CUSP Boards where infection rates were posted monthly
Fun Competition
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CUSP Sustainability and Expansion
After about 6 months, noticed modest gains in monthly rate reduction Decided to host more CUSP trainings with video about
Josey King
At 9 months – CUSP went housewide! (Med Surg and Pulmonary floors)
Recruited different physician champions and unit/floor champions with same administrative champion
Champions brought others on board with roll-out and were instrumental in CUSP success
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Townhall Discussion
Data resources used Education tactics – Science of Safety and CUSP
directed initiatives Engagement tactics – Executive and front line staff Team member selection and team building Scheduling concerns – consolidate with other
meetings vs separate timing Investigations of defects Feedback methods Sustainability
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Townhall Discussion
What is your hospital doing as an alternative to CUSP?
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Feedback on CUSP Trainings and Resources
Fall LAN Meeting
AHRQ/HRET National Webinar on CUSP
http://hai.ipro.org
Quarterly Newsletters – CUSP Corner
Today’s Webinar/Townhall
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This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM7.1-12-04
For more information
Teré Dickson, MD, MPHMedical Officer(516) [email protected]
IPRO CORPORATE HEADQUARTERS
1979 Marcus AvenueLake Success, NY 11042-1002
IPRO REGIONAL OFFICE
20 Corporate Woods BoulevardAlbany, NY 12211-2370
www.ipro.org
Template 1/13/2012
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