0:05
The comprehensive unit-based safety program was
our method of meeting the adaptive challenges in quality improvement work.
It was still in its infancy when we moved into the Michigan Keystone project.
We only had probably a dozen units or
more at Johns Hopkins that were actually doing some of this works.
So some of the tools that we developed to meet the adaptive needs were actually done
during the Michigan Keystone project or revamped for this program.
But because we had had such success with the CUSP program,
we decided to bring that with us.
And the CUSP program had since or has since been used for
national implementation of CLABSI and for national implementation of VAP,
so it was very successful.
It definitely showed that we could improve culture and teamwork while
meeting the adaptive challenges that introducing new technical work provides.
So one of the first things that that we do is we want people to all be on the same page.
That is watching the science of safety and this is for everybody.
This is for the CEO,
the chief medical officer,
the frontline providers, whether they be physicians or nurses and even our technicians.
We want everybody to understand that this is the video that
gives you the opportunity to have the lenses to see potential for patient harm.
This is the opportunity where we teach you why it's so important to standardize care,
why it's important to do independent checks of redundancy,
and why as a high reliable organization you want to focus on errors.
And the reason we focus on errors is because we want to learn secondary problem solving,
meaning we don't want to just put out the fire which is primary problem solving.
We want to prevent the event from occurring again.
So if we can prevent CLABSIs or any other hospital acquired injuries,
that is really what we're there for.
So to have the lenses to see the type of errors that we are out there.
And we mandated that everybody participating in the program watch the science of safety.
We also provided them with video clips so that whenever
they had new staff or they had residents changing rotation,
they all got an opportunity to see the science of safety.
So everybody coming in got the training
and everybody that changed outing and came back to do
the work got the science of safety so that they would have those lenses to
see error and to identify how they
might prevent that from coming to their patients again.
So the second one is identifying defects and we
wanted the defects to come from all over the organization,
so they could come from risk management,
they could come from adverse event reporting that
we reviewed monthly and our costs meetings,
they could come from hospital epidemiology who told us what our infection rates were,
because we now knew that hospital acquired infections were preventable,
that was a preventable harm.
But also using the Wisdom of the Crowd.
So it's a great book that we read,
I'm talking about allowing us to get input from the frontline providers,
so we developed a tool.
One of the CUSP tools called the staff safety assessment.
It asks two questions,
how do you think the next patient is going to be harmed.
And the second question is how do you believe you could prevent that harm from occurring?
Now what this does was not only optimize your CUSP team because it
allows them to independently work
on some of the defects that they've identified within their own unit.
So in addition to working on CLABSI or VAP,
they could also work on other things that were
showing up in their unit like medication errors,
or falls, or decubitus or any other things that we didn't want to have happen again.
So very important because it brought
buy-in from the frontline providers and people that were really
interested in building capacity actually began
working on some of these safety issues
and they were active participants in the CUSP team.
The next thing was partnering with the senior executive.
And as I've said several times we often work in our organization.
We may know the names of our senior executive,
but we interact with them very rarely.
What this did was allow your senior executive to adopt your unit
and the senior executive would come to every one of your CUSP meetings.
He or she would review your data with you.
So your infection control data,
your adverse event data,
and they were a partner as you move forward.
It was a way to reduce the hierarchy.
So you were on a much more first name basis.
And this person was really there to guide
you through the big organization that you worked in,
to all the things that he knew about
how the organization functions so that he helps steer you to
some of the resources and some of
the mechanisms for change that you would need going forward.
The next thing and we talk about this a lot,
but learning from those defects and so not only do we learn from each new CLABSI,
but we learned from the defects that we've identified and there's a separate CUSP tool,
that there is a video clip about.
And really what it does is it shows us that it's important to document the event,
and this is something that is not part of the permanent record,
and then to review the event how it happened, why it happened.
Why it happened is based on those system defects.
So is it because somebody didn't have adequate training?
Is it because there was an IT problem?
And so maybe the MAR was printed out incorrectly.
There's lots of different reasons.
But then not only why did it happen,
what were the system factors that limited the impact of the event?
So let's say a patient extubated themself,
which could be catastrophic especially if they had a difficult airway.
But if you worked in a unit where you always had anesthesia residents,
or you had an anesthesia resident or a fellow or even attending that was there bringing
a patient who quickly saw that the patient
was in need of re intubation and they stepped in to do that.
That would be one of the system factors that
you would say this limited the impact of the defect.
So very important.
Why, what limited it,
and then what are you going to do to fix it,
and then how do you know you fixed it?
So you could do something as simple as developing a policy.
But then we also want to know did the policy work.
So you have to go around to your frontline providers and ask them,
do you understand the policy,
are there any flaws to the policies,
are there barriers to implementation?
And then you look to see was that policy actually effective
at getting what you wanted done which was to prevent that defect from occurring again.
And then lastly, because teamwork is such a big issue,
we want to, and communication even bigger,
we want to improve teamwork and communication.
And the reason we want to do that is teamwork,
communication, are both very high ranking when we look at adverse events.
Probably the number one cause of adverse events is often communication or poor teamwork,
or poor understanding of both.
And so we develop
the CUSP tools which address some of those teamwork and communication problems.
Tools like the daily goals,
which allows us to get the patient up and out of ICU much quicker.
Tools like the shadowing tool so that
different providers can understand what each other's roles are.
Morning briefing that teaches you how to prioritize which patients to see in the morning.
But there are lots of different tools out there and all of them
improve our ability to connect with each other and to have
a shared mental model so that we're communicating about
the same thing and we understand when we have to step in and be good team players.
Starting CUSP, we usually say start with one unit.
Now we had several units that began in some hospitals that were large,
they had a few that began.
Learned from what the first unit learned.
So if there are things that they've addressed as barriers,
go ahead and kind of address those as you move forward.
It's imperative that the frontline staff be involved.
In fact, we always say in planning and attending the frontline staff meetings,
that the frontline staff be there.
So it doesn't do any good just to have
the physician champion who might be the director and the nurse manager to be there.
You have to have people that are actually at
the bedside that understand what it's like to work at the bedside,
that can explain why those defects occur,
and some of the potential things that they've thought about.
And they can also tell you frequency.
So if you don't have a list of adverse events that are coming from you,
when you look at your staff safety assessment and you collate what you find,
you can identify what you want to work on based on how frequently does this event occur,
but also what's the acuity like.
How serious is this event type.
And really this is a way of getting everybody
to build capacity in quality and safety for those frontline providers.
We have always recommended that somebody from
hospital epidemiology infection control be present.
We ask that they report out on our current patients that are on isolation,
what our infection rates were,
what our hospital acquired infection rates were.
And we love having a nurse educator and I tell you why.
So a nurse educator is really important if you have one and they play a major role,
not only because they're used to educating frontline staff,
but because they have multi methods to go ahead and train you.
The other thing that we found is that
an educator is more likely to make sure that any new staff,
whether that be a new resident on a new rotation or a new nurse or new tech,
all have the same education on
infection reduction on the CUSP program and they sign off on that.
So that is one way to keep your CUSP staff current,
is to have that educator that's there to go ahead and make sure that there's
no break in education for not only the evidence based practice bundle you're doing,
but the CUSP program.
And then for physician champions or physician leaders, very important.
We always say to pick somebody that's well respected,
well skilled, somebody that the other physicians are going to look up to.
Somebody that can move their agenda forward.
And then other diverse input and you might say who would that be.
So for us sometimes it's been social work.
It's been cleaning staff.
One of the big things when we are talking about
infection reduction was how we clean
our room and how do we know our room was clean enough.
And so we found that with transplant patients,
we changed everything out in the room.
But there were other patients that were just as I would say vulnerable to infections.
Somebody maybe that had, you know,
that was an oncology patient,
that should really have their room treated in a same way.
So who you need is also very important.
If you're in a respiratory unit,
you definitely have to have a respiratory therapist.
If you have a point of care pharmacist,
that somebody also to consider if medication errors are big.
But as I said,
it doesn't really, there's no limitation.
They don't have to be a clinician.
So we've found cleaning staff to be important.
We've found unit clerks to be important,
and we include them in our CUSP meetings and they bring a lot to the table.
David Thompson DNSc, MS, RNAssociate Professor
