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Cusp what is it how are we going to cause the next infection liza_deb
1. Š The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
CUSP
Getting Started
Elizabeth C. Wick, M.D.
Deborah B. Hobson, B.S.N, R.N.
2. Objectives
â˘To outline the steps of the comprehensive
unit based safety program (CUSP)
â˘To describe the use of adaptive and
technical changes to prevent infections
and improve surgical care
4. History of CUSP
⢠Started at Johns Hopkins Hospital in 2001
⢠A perfect storm created an atmosphere that
supported CUSP
â IOM report
â A tragic patient event
â Organizational management research
â Work to decrease/eliminate blood stream
infections
⢠First units establishing CUSP at Johns Hopkins
were ICUs
5. Where is CUSP?
⢠47 Units + at Johns Hopkins Hospital starting 2001
â ICUs, in-patient units, outpatient clinics, procedure
areas, rehab areas, PACUâs, ORs, pharmacies
⢠State collaboratives
⢠National collaboratives (2009- present)
⢠International
â Canada, Spain, England, Peru, UAE, Portugal,
Mexico, and others
6. Power of CUSP
⢠Designed to improve safety culture and learn from
mistakes
⢠Structured framework that can be implemented
throughout an organization
⢠Values wisdom of frontline staff
⢠Empowers staff to be actively involved in safety
improvements
⢠Helps eliminate barriers between staff and senior
leadership
7. Johns Hopkins ICU program1
Michigan Keystone ICU program2,3
National On the CUSP: Stop BSI program
Reductions in central line-associated blood
stream infections (CLABSI)
1.Crit Care Med. 2004;32:2014-20.
2.N Engl J Med 2006;355:2725-32.
3.BMJ 2010;340:c309.
Successful Efforts to Reduce
Preventable Harm
8. Comprehensive Unit
based Safety Program
(CUSP)
1. Educate staff on
science of safety
2. Identify defects
3. Assign executive
to adopt unit
4. Learn from one
defect per quarter
5. Implement
teamwork tools
Translating Evidence
Into Practice
(TRiP)
1. Summarize the
evidence in a checklist
2. Identify local barriers to
implementation
3. Measure performance
4. Ensure all patients get
the evidence
⢠Engage
⢠Educate
⢠Execute
⢠Evaluate
Reducing Surgical Site
Infections
⢠Emerging Evidence
⢠Local Opportunities
to Improve
⢠Collaborative
learning
Technical Work Adaptive Work
9. The Vision of CUSP
â Improve patient safety awareness and systems
thinking at the unit level
â Empower staff to identify and resolve patient
safety issues
â Integrate Safety Practices into daily work of all staff
members
â Create a patient safety partnership between
executives and frontline caregivers
â Provide tools to help CUSP teams investigate and
learn from defects and improve teamwork and
safety culture
9
10. CUSP Steps
CUSP
1.Educate everyone in the Science
of Safety
2. Identify defects (2 question
survey)
3. Recruit executive as active
CUSP team member
4. Learn from one defect per
quarter
5.Implement teamwork tools
Pre-CUSP
1.Conduct the culture assessment
2.Establish interdisciplinary CUSP
team
3.Partner with senior executive
4.Gather unit outcome and safety
information
11. What is Culture*?
âThe way we do things around hereâ
Health and safety commission, 1993
Denham, 2007
1 attitude = opinionâŚeveryoneâs attitude = culture
*aka Climate Slide courtesy of J. Bryan Sexton
12. Research has linked teamwork and safety climate to:
⢠Decubitus Ulcers
⢠Delays in OR and ICU
⢠Bloodstream Infections
in the ICU
⢠Ventilator Associated Pneumonia
â˘Wrong Site Surgeries
⢠Post-Op Sepsis
⢠Post-Op Infections
⢠PE/DVT
⢠RN Turnover
⢠Absenteeism
⢠Incident Reporting Rates/
Reporting Harm
⢠Burnout
⢠Spirituality
⢠Unit Size
Why Culture MattersâŚ
Colla, J.B. 2005
Slide courtesy of J. Bryan Sexton
13. Š The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
WICUPOSTCUSP
--SICUPOSTCUSP
--SICUTime3
--WICUTime3
WICUPRECUSP
SICUPRECUSP
0
10
20
30
40
50
60
70
80
90
100
S IC U
P R E
C U S P
%ofrespondentswithinaclinicalareareportinggoodsafetyclimate
Safety Climate Across 100 Clinical Areas
WICU & SICU Climate Pre-Post CUSP
14. %ofrespondentswithinanICUreportinggood
teamworkclimate
Teamwork Climate Across Michigan ICUs:
Keystone ICU Project
Â
                        No BSI (21%)No BSI (21%)                     No BSI 44%No BSI 44%                  No BSI 31%No BSI 31%
No BSI = 5 months or more w/ zero
14
15. Surgical Infections
(per 1000 discharges)
0
0.5
1
1.5
2
2.5
OR Safety Climate Level
Group Average Low OR Safety Climate Mid OR Safety Climate High OR Safety Climate
AHRQ National Average
Source: Bryan Sexton
16. Culture in Safe Organizations
⢠Commit to no harm
⢠Focus on systems not people
⢠Value Communication/teamwork
⢠Accept responsibility for systems in which
we work
⢠Recognize culture is local
⢠Seek to expose (not hide) defects
⢠Celebrate safety
17. CUSP Steps
CUSP
1.Educate everyone in the Science
of Safety
2. Identify defects (2 question
survey)
3. Learn from one defect per
quarter
4. Implement teamwork tools
Pre-CUSP
1.Conduct the culture assessment
2.Establish interdisciplinary CUSP
team
3.Partner with senior executive
4.Gather unit outcome and safety
information
18. CUSP OR Team Members
Essential Team Members
⢠Surgeons
⢠Anesthesiologists
⢠CRNAs
⢠Circulating nurses
⢠Scrub nurses / OR techs
⢠Perioperative nurses
⢠Executive partner
⢠Nurse leaders
Enhancing Team Members
⢠Physician assistants
⢠Nurse educators
⢠Anesthesia assistants
⢠Infection preventionists
⢠OR directors
⢠Patient safety officers
⢠Chief quality officers
⢠Ancillary staff
18
19. Andy Benson CRNA
CRNA Lead
Deb Hobson
BSN
âCoachâ &
Patient Safety
Officer for
Surgery
Tracie Cometa RN
Lead RN
Sean Berenholtz MD
Anesthesia Lead
Lucy Mitchell RN, MS
NSQIP SCR
Elizabeth Wick MD
Surgery Lead
Renee Demski MBA
Senior Director Quality
Johns Hopkins Medicine
Executive
Steph Mullens CST
Lead Tech
Mary Grace Hensell RN
Manager OR
20. CUSP Steps
CUSP
1.Educate everyone in the Science
of Safety
2. Identify defects (2 question
survey)
3. Recruit executive as active
CUSP team member
4. Learn from one defect per
quarter
5.Implement teamwork tools
Pre-CUSP
1.Conduct the culture assessment
2.Establish interdisciplinary CUSP
team
3.Partner with senior executive
4.Gather unit outcome and safety
information
21. Gather Unit Information
Information for executive and team
â˘Culture Survey Results
â˘List of safety issues
â Event reporting system summaries
â˘Outcome data (NSQIP, other registries)
â˘Patient satisfaction surveys
â˘Unit statistics
â Number of beds -
â Staff/patient ratio
â Staff turnovers -
â Fall rates
21
22. Does SCIP gives us enough
information?
Johns Hopkins
Comparison
Hospitals
Surgery patients who were
given an antibiotic at the
right time (within one hour
before surgery) to help
prevent infection
98% 97%
Surgery patients who were
given the right kind of
antibiotic to help prevent
infection
98% 98%
Surgery patients whose
preventive antibiotics were
stopped at the right time
(within 24 hours after
surgery)
97% 96%
Surgery patients needing
hair removed from the
surgical area before
surgery, who had hair
removed using a safer
method (electric clippers or
hair removal cream â not a
razor)
100% 100%
Patients having surgery
who were actively warmed
in the operating room or
whose body temperature
was near normal by the end
of surgery.
98% 99%
Johns Hopkins Hospital
May 2010 SCIP
Hospital Compare
www.medicare.gov
24. CUSP Steps
CUSP
1.Educate everyone in the Science
of Safety
2. Identify defects (2 question
survey)
3. Recruit executive as active
CUSP team member
4. Learn from one defect per
quarter
5.Implement teamwork tools
Pre-CUSP
1.Conduct the culture assessment
2.Establish interdisciplinary CUSP
team
3.Partner with senior executive
4.Gather unit outcome and safety
information
25. Science of Safety
⢠Every system is perfectly designed to achieve the
results it gets
⢠Understand principles of safe design
â standardize, create checklists, learn when things
go wrong
⢠Recognize these principles apply to technical and
adaptive work
⢠Teams make wise decisions when there is diverse
and independent input
Caregivers are not to blame
25
26. Educate the entire team on the
Science of Safety
â˘Science of Safety Video
to be viewed later today
â˘Share the Science of Safety Fast
Facts with team members
26
27. Science&of&Improving&Patient&Safety&Fact&Sheet:&&
CUSP&for&Safe&Surgery&
Why&the&science&of&safety&matters1&
â˘
â˘
â˘
â˘
Why&medical&errors&happen&
â˘
â˘
⢠in the healthcare system that lead to complications vary widely among hospitals
Surface&Defects&that&are&leading&to&complications&
Tap into the wisdom of frontline
staff. Ask frontline staff how the next
patient will be harmed and what we
can do to prevent it.
Audit local performance to
identify opportunities to improve.
Create your own âbundleâ
of care and focus on
improving the system to
prevent complications.
Consider&your&work&area:&What&systemAlevel&factors&put&patients&at&ris
Work&with&your&teams&to&apply&principles&of&safe&design&&
27
28. CUSP Steps
CUSP
1.Educate everyone in the Science
of Safety
2. Identify defects (2 question
survey)
3. Recruit executive as active
CUSP team member
4. Learn from one defect per
quarter
5.Implement teamwork tools
Pre-CUSP
1.Conduct the culture assessment
2.Establish interdisciplinary CUSP
team
3.Partner with senior executive
4.Gather unit outcome and safety
information
29. Two Question Survey
1. How will the next patient develop a
wound infection?
How can we prevent the next wound
infection?
2. How will the next patient be harmed?
How can we prevent that harm?
29
30. Surgery Staff Safety Assessment
Staff Safety Assessment â ORCUSP
1. Please describe how you think the next patient in your unit/clinical area will be harmed.
Name:
Job Category:
Date:
Please describe what you think can be done to prevent or minimize this harm .
2. Please describe how you think the next patient in the OR will get a Surgical Site Infection.
Please describe what you think can be done to prevent this infection.
30
31. How will the next patient be harmed?
(SSI Specific)
Percentage of Responses (%)
95 Responses from 36 Staff Members95 Responses from 36 Staff Members
31
Wick, et al. 2012.
32. 32
CUSP Step 2:
Safety Issue Identified
CUSP Steps 4 : Learn from Defects
Opportunities to improve
Infection Control ⢠Skin preparation
⢠Hypothermia
⢠Contamination of bowel contents into the wound
⢠Antibiotic timing
⢠Selection and redosing
⢠Length of case
Coordination of Care ⢠Increase utilization of preoperative evaluation center,
⢠Improve surgical posting accuracy (case name and duration)
⢠Computer assistance for antibiotic selection and redosing
Communication and Teamwork ⢠Improve communication throughout perioperative period
⢠Empower team members to speak up
⢠Improve compliance with briefings/debriefings
⢠Implement teamwork tools
Equipment/ Supplies ⢠Accurate temperature probes
⢠Point of care glucose monitoring
⢠Under body warmers
⢠Sanitizing wipes near anesthesia machine
Policies/Protocols ⢠Standardize care/protocols/policies
⢠Monitor sterile technique policies
Education/Training ⢠Ongoing education (with supportive data)
⢠Development of a SSI prevention checklist
Wick, et al. 2012.
33. CUSP Steps
CUSP
1.Educate everyone in the Science
of Safety
2. Identify defects (2 question
survey)
3. Recruit executive as active
CUSP team member
4. Learn from one defect per
quarter
5.Implement teamwork tools
Pre-CUSP
1.Conduct the culture assessment
2.Establish interdisciplinary CUSP
team
3.Partner with senior executive
4.Gather unit outcome and safety
information
34. Gentamicin
Interventions:
⢠Increased amount of
gentamicin available
in the room
⢠Added dose
calculator in
anesthesia record
⢠Educated surgery,
anesthesia and
nursing in grand roundsDespite >95% compliance on SCIP
36. Skin Preparation
Interventions:
â˘Chlorehexidine wash cloths given to patients pre-
operatively
â˘Surgical skin preparation standardized to
chloraprep (even in patients with ostomies)
â˘Prep responsibility shifted to circulating nurse from
resident
â˘All nurses trained on chloraprep application
37. Separation of âDirtyâ and âCleanâ
Instruments
Intervention:
⢠Built separate tray of
instruments used for bowel
anastomosis
⢠Extra suction and bovie tip
and gloves opened and
changed after
anastomosis
⢠Educational sessions with
scrub techs and nurses
about instrument
separation
⢠Audits and education on
the spot
39. SSI Prevention Interventions
⢠Use of pre-operative chlorhexidine washcloths
⢠Pre-warming in the pre-op area
⢠Standardized skin preparation with chloraprep
⢠Separation of dirty and clean instruments
39
40. CUSP Steps
CUSP
1.Educate everyone in the Science
of Safety
2. Identify defects (2 question
survey)
3. Recruit executive as active
CUSP team member
4. Learn from one defect per
quarter
5.Implement teamwork tools
Pre-CUSP
1.Conduct the culture assessment
2.Establish interdisciplinary CUSP
team
3.Partner with senior executive
4.Gather unit outcome and safety
information
41. Teamwork Tools:
SSI Intervention Checklist
Complete for Surgeons: Wick, S. Gearhart,
J. Efron, Safar, Fang & Marohn
Colorectal SSI Project Intervention Checklist
Place completed form in âColorectal Mail Slotâ in PACU
COMPLETED BY: DATE:
Yes No
YES NO NA
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
CHLORAPREP WASHCLOTHS AT HOME?
PRE-OP WARMING: Bair hugger placed on
patient in pre-op?
Temp on admission to PREP
Temp when leaving PREP
Did patient do MECHANICAL BOWEL PREP?
And take all ORAL ANTIBIOTICS?
If NO, why? _________________________
ROOM TEMPERATURE: warmed to 72
degrees prior to patient arrival?
PROPHYLAXIS ANTIBIOTIC SELECTION?
Check box for antibiotic given:
Standard: Cefotetan 2gm or Cefoxitin
2gm
Penicillin Allergy: Clindamycin plus
Gentamicin 5mg/kg
SKIN PREPARATION: Chloraprep completed
by RN or Surgical Attending?
INSTRUMENTS: Clean and dirty
instruments separated?
HYPEROXIA administered In OR?
In PACU or ICU? (Timing: ____ to ____)
Patient Sticker
Please
Circle
One
For
Each
45. Root Causes of Hospital
Sentinel Events
0 10 20 30 40 50 60 70
Organization culture
Alarm systems
Procedural compliance
Competency/credentialing
Continuum of care
Physical environment
Staffing levels
Availability of info
Patient assessment
Orientation/training
Communication
Percent of events
45
46.
47. Teamwork
Surgeon: If the nurse follows my
orders
Nurse: If the surgeon listens to my
concerns
Armstrong Institute for Patient Safety and Quality
48. Š The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
Â
%Agree âI know the names of the personnel I
worked with during my last shift.â
50. Š The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
51. Â
%Agree
Makary et al. Operating room briefings and wrong-site surgery. J Am Coll Surg 2007;204:236-43.
It was difficult to speak up if I perceived
a problem with patient care.â
52. Briefing/Debriefing Form
Privileged and Confidential - For Peer Review Purposes Only
The Johns Hopkins Hospital
Operating Room Briefing/ Debriefing ToolŠ
Attending Surgeon to utilize this tool is to prompt open interdisciplinary communication before and after
surgery to promote a clear understanding of specifics for each case.
ORMIS Case #___________________ Date ________________
Â
Briefing â Before Every Procedure
⢠Team introductions â first and last names including roles  (Circulator writes on board)Â
⢠Do the following match:Â
⢠Patient ID band, Informed Consent (read out loud), Site Marking, OR posting, patientâs verbalization of procedureÂ
(if patient awake), other clinically relevant documentation (H&P, clinic note)Â
⢠Do we have any safety, equipment, instrument, implant or other questions or concerns?Â
⢠Have antibiotics been given, if indicated?Â
⢠What are the anticipated times of antibiotic redosing?Â
⢠Is glycemic control/ beta blockers indicated?Â
⢠Is the patient positioned to minimize injury?Â
⢠Has the Prep been applied properly, without pooling and allowed to dry?Â
⢠Have the goals and critical steps of the procedure been discussed?Â
⢠Is the appropriate amount of blood available? Â
⢠Is DVT prophylaxis indicated? If so, what?Â
⢠Has the patient received anticoagulants?Â
⢠Any Special Precautions? If yes, describe.                                                            Â
⢠Are warmers on the patient?Â
⢠Is the time allotted for this procedure an accurate estimate?Â
⢠Has Attending reviewed latest/ final test results for Lab/ Radiology? Are Intraoperative X rays indicated?Â
____________________ _____________________ ________________________
Circulating Nurse Anesthesia Provider Attending Surgeon
Debriefing â After every procedure
⢠Could anything have been done to make this case safer or more efficient?Â
⢠Has the SSI data collection form been completed?Â
⢠Are the patient name/ history number and the surgical specimen name and laterality Â
 on the paperwork? (Paperwork/ labeling to be independently verified by Surgeon)Â
⢠Did we have problems with instruments? Â
⢠Plan for transition of care to post-op unit discussed? To include:Â
⢠Fluid Management/ blood (all slips in chart)Â
⢠Antibiotics â continue post-op (dose/interval)Â
⢠PACU tests/ XraysÂ
⢠Pain/ PCA planÂ
⢠New meds needed (immediate periop)Â
⢠Beta blockers (as required)Â
⢠Glycemic control (as required)Â
⢠DVT prophylaxisÂ
_________________ ________________________ ________________________
Circulating Nurse Anesthesia Provider Attending Surgeon
06-07Â
Â
Â
Â
Â
Addressograph hereÂ
⢠No follow-up on
comments
⢠Too long
⢠Same form used in all
ORâs (neurosurgery,
ortho, general
surgery)
53. Briefing and Debriefing
âreal-timeâ identification of defects
⢠Team developed new
form based on specific
needs
⢠Candid discussion with
surgeons about
effective strategies for
briefing/debriefing
⢠RN given protected
time to address defects
and communicate fixes
⢠Logbook of defects
 Â
Â
Before induction of anesthesia  Before skin Incision  Before patient leaves OR Â
Â
55. Example of Defects Addressed:
Instruments
Problem: Conflict with
colorectal set
â˘Increased fleet from 2 to 4
â˘Reorganized contents of set
so it is only pulled for cases
when it is really needed
Impact: Instruments
available when needed
55
56. Example of Defects Addressed:
Instruments
137 instruments
54 instruments
Impact:
Fewer instruments to count and turnover
Save money and time
Revision of Laparoscopic GI Surgery Trays
Problem: Many open instruments set up
for lap cases which were never used
57. Examples of Defects Addressed:
Postings
Problem: Circulating RN and scrub could not tell from posting if an
abdominal and perineal set-up was needed for a case
â˘Worked with posting office to add âsecond setup neededâ to posting sheet
and surgeon notes section in ORIMIS
Impact: RN and scrub can set up before discussing case with surgeon, fewer
delays
57
58. Examples of Defects Addressed:
Updating DPCs
Problem: Equipment, supplies and/or
instruments not available for cases
â˘Decreased number of DPCs
â˘Removed argon from colorectal DPCs
â˘Decreased surgeon to surgeon
variability (standardization)
â˘Increased accuracy
Impact: Fewer errors, less counting
required, less instruments to return at end
of case, increased efficiency
58
59. Hidden Cost-Savings
Antibiotic Irrigation
⢠Frontline providers questioned the
inconsistency in use of antibiotic
irrigation between surgeons
⢠Solution: if effective, advocate for
consistent use and if not proven
stop using
⢠NO EVIDENCE TO SUPPORT USE
⢠$537,000/ year on antibiotic
irrigation
⢠Obtained surgeon and leadership
buy-in for removing it from
hospital formulary
60. Briefing Audit Tool
Audits done by:
Jennifer Bennett BA (medical student)
Anna Chay BA (nursing student)
Deborah Hobson RN (patient safety
officer)
Mike Rosen Ph.D.
Sallie Weaver Ph.D.
60
64. SSI Investigation Process
⢠Every month
⢠Patients with
infections identified
by NSQIP
⢠Data abstracted by
hand from ORIMIS,
Metavision, POE, EPR
64
65. Surfacing Defects on Patients with
Infections
Q1 2012 Q2 2012
Patients with Infections 15 19
CUSP group surgeons 9 11
Antibiotic Selection 100% 100%
Antibiotic Timing 100% 100%
Warmer Use in OR 100% 100%
SCIP Measures:
66. Surfacing Defects on Patients with
Infections
Q1 2012 Q2 2012
Patients with Infections 15 19
CUSP group surgeons 9 11
Antibiotic Dose (Gentamicin) 50% 100%
Redosing 20% 0%
Pre-op Warming* 55% 27%
Incision Temp 44% 27%
End Temp 44% 82%
Recovery Room Temp 100% 91%
Washcloths Use Pre-op* 55% 9%
Standardized Skin Prep* 77% 64%
Bowel Prep with Oral
Antibiotics* 55% 36%
Reduced Steroid Dosage 0% 100%
Normothermia
*CUSP
67. Addressing Defects:
Tablet-based Pre-op Education
Problem: Patients did not know
why we do the preparations
we do
⢠Enhanced pre-op education
to improvement patient
compliance with preparation
for surgery
⢠Interactive
⢠Teachback
68. Addressing Defects:
Bowel Prep Kit and Reminder Call
Problem:
Patients frequently scheduled months
before surgery and materials not
available in all pharmacies
⢠Patients will be given bowel prep
materials when scheduled for
surgery
⢠Reminder phone calls 2 days
before procedure
Erythromycin
Neomycin
Biscodyl
Dec 2012-Jan 2013
35 pts contacted
31/35 (89%) compliant with washcloths
70. 70
Addressing Defects:
Chlorhexidine Washclothes Day of Surgery
Problem:
Patients not using pre-op
chlorhexidine washclothes
⢠Patients will be reminded
with phone calls
⢠Prep will provide
washclothes on the day of
surgery for patients who
did not use
73. Sustaining Quality Improvement
⢠Creative tools to surface new defects
â˘Event reporting
â˘Briefing/debriefing
â˘Readminister staff safety assessment
⢠New technical projects
â˘Pathways/ length of stay
â˘Efficiency/ throughput
â˘Patient satisfaction
74.
75. Reassess Data
NSQIP SAR 2013
Armstrong Institute for Patient Safety and Quality
76
⢠The good⌠no longer a high outlier for SSI
⢠The bad⌠high outlier for length of stay
76. Goal of ERAS
⢠Implement a standardized, patient centered
protocol
⢠Integrate the pre-operative, intra-operative,
post-operative and post-discharges phases of
care to reduce LOS
⢠Improve patient experience and satisfaction
and decrease variability
77. ERAS
Main shifts in mentality
⢠Pain management
â Goal is to diminish narcotic intake
⢠Fluid management
â Goal is to avoid volume overload â bowel edema
⢠Prevent starvation
â Pre-op carbohydrate drink and early feeding after
surgery
⢠Activity
â Goal is to induce early mobility and get the bowels
moving!
78. Engaging Executive and Additional
Providers Support
Armstrong Institute for Patient Safety and Quality
80
Chris Wu, M.D. Liz Lins, MSN
Anesthesiology/ Pain Management Nurse Manager, Marburg 2
Dreama Franklin, RN
Care Coordinator
Val Gaskins, RN
ERAS Coordinator
Ron Werthman Claro Pio Roda John Hundt, MHS Peter Pronovost, MD, PhD
CFO Administrator, Anesthesia Administrator, Surgery SVP Quality and Safety
79. Financial Analysis to Support
Incremental Cost of Program
Expenses:
â˘Surgeon and anesthesiologist 20% time
â˘Nurse to support implementation
â˘Nurse practitioner to expand capacity of pain service
â˘Massimo fluid monitors (3)
â˘Bis monitors
84. Our Model
Comprehensive Unit
based Safety Program
(CUSP)
1. Educate staff on
science of safety
2. Identify defects
3. Assign executive
to adopt unit
4. Learn from one
defect per quarter
5. Implement
teamwork tools
Translating Evidence
Into Practice
(TRiP)
1. Summarize the
evidence in a checklist
2. Identify local barriers to
implementation
3. Measure performance
4. Ensure all patients get
the evidence
⢠Engage
⢠Educate
⢠Execute
⢠Evaluate
Reducing Surgical Site
Infections
⢠Emerging Evidence
⢠Local Opportunities
to Improve
⢠Collaborative
learning
Technical Work Adaptive Work
86. Lessons Learned
⢠Colon SSIs can be prevented and outcomes improved
⢠Change can not be âtop downâ
⢠CUSP sends a clear message, all provider opinions and
ideas are important and essential for improvement
⢠Better teamwork ď better outcomes ď better culture and
teamwork
⢠It takes time, commitment and leadership support
87. Johns Hopkins Hospital Motto
Our experience: Hospital level
interventions(SCIP) pale in comparison to
interventions at the work unit level (CUSP)
We embrace local wisdom in for the care of
colorectal surgery patients
Notas do Editor
First round notes:
Add to the âreducing SSIsâ block âEmerging evidence, local opportunities to improve, collaborative learning
NOTE: emphasize that we are coupling technical and adaptive work
Think about color coding pieces (should Trip & CUSP be the same)
Educate and improve awareness about patient safety and quality of care to ALL PROVIDERS (techs, nurses, anesthetists, surgeons, residents)
Empower staff to take charge, put their local wisdom to use, and improve safety in their work place
Their voice NEEDS to be heard
Partner unit with an actively participating hospital executive
Send a message to frontline staff about the importance of the work
Provide resources for unit improvement efforts
Hold team accountable for improvement
Provide tools to monitor outcomes, investigate and learn from defects and improve teamwork and safety culture
First round notes:
Emphasize role of hospital executive (how to make that more explicit)
Emphasize that âthis program taps into the wisdom of local staffâ (not just empowering)
Must educate staff so they have the knowledge to improve their workplace.
Must be staff driven or they wonât be empowered to take charge and improve care.
Now this is the slide that truly demonstrates the change in safety climate after CUSP was implemented and I am one of the nurses in the SICU group âso I can truly tell you that CUSP works!!! So we started CUSP-we had an executive meet with us monthly, we started safety projectsâŚ. And now after 1 year we were at 68% and now we are greater than 80%-- so CUSP truly has an impact. I see it as the umbrella with all the other safety initiatives dangling below it⌠I can not stress enough to start with CUSP than implement the different safety initiatives..
Low safety climate is more like moderate or neutral safety climate -
Speak up when you have concern
Listen when others have concerns
Support/Train Teamwork
Reinforce Situational awareness
Tell others about the defect so it does not occur else where
Our needle high in the stackâŚ.
Step 3 â Executive helped by allowing the finances to pilot the foley Temps
Explain SlideâŚ
âIf everyone follows my orders, then the teamwork is greatâ
Why the big disconnect???
We went back and asked them what they meant by teamworkâŚ.
Yet when we look at the operating room, what we see is a workplace littered with anonymity.
In the Safety Attitudes Questionairre, we asked surgical staff if they know the names of their collegues they work with in their OR or unit? Slide
We learned some fascinating things
WHOâS ON the SHIP?
Iâm guilty of this. When you operate in the room next John Cameron, somehow magically I end up with nursing student fresh out of school every day.
KNOWING SOMEONES NAME GIVES THEM DIGNITY AND VALUE. IT ELIMINATES ERRORS OF ANONYNITY, and gives value to members of the team.
ITâS THE BASIS FOR THE FOREMOST ITEM OF THE CHECKLIST:
Many surgeons and OR teams have for years developed standardized routines to make sure nothing gets missed. In working with Atul and the W.H.O. we all agreed that the most important routine was to make sure everyone knew who everyone else was at the beginning of the operation.
Explain slide
Call me âmartyâ. Now they come in saying Hi Dr. Megid, Hi Dr. Brook, oh HI MARTY
This is a messâŚNeed to redo
First round notes:
Add to the âreducing SSIsâ block âEmerging evidence, local opportunities to improve, collaborative learning
NOTE: emphasize that we are coupling technical and adaptive work
Think about color coding pieces (should Trip & CUSP be the same)
We need to be at the table
Available
Enthusiastic
BUT, our voice should not always be the loudest
Engage other frontline providers
Guide discussion
Serve as facilitator