Using CUSP as a Framework for Improving Patient Safety (Text Version)

Slide presentation from the AHRQ 2011 conference.

On September 19, 2011, Steve Levy made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (960 KB). Plugin Software Help.


Slide 1

 Using CUSP as a Framework for Improving Patient Safety

Using CUSP as a Framework for Improving Patient Safety

Steve Levy
Director of Operations
Michigan Health & Hospital Association (MHA) Patient Safety Organization (PSO)

Slide 2

 Topics

Topics

  • Overview of the Michigan Health & Hospital Association collaboration team.
  • What is the Comprehensive Unit-Based Safety Program (CUSP)?
  • CUSP as a framework for improving patient safety.
  • How the MHA PSO collaborates with MHA Keystone using CUSP to improve patient safety in the operating room: process and results.

Slide 3

 The Team

The Team

ECRI Institute:

  • Data Warehousing.
  • Expertise.
  • Patient Safety Resources.

MHA Patient Safety Organization (PSO):

  • Data Analytics.
  • Coordination of resources.
  • Expertise.

MHA Keystone Center for Patient Safety and Quality®:

  • Collaborative management.
  • Interventions.
  • Expertise.

Vision: Health care that is free of harm.

Slide 4

 MHA Keystone Center Michigan Collaboratives

MHA Keystone Center Michigan Collaboratives

CollaborativeParticipating
Hospitals
Keystone: ICU77
Keystone: Hospital-Associated Infection120
Keystone: Surgery104
Keystone: Obstetrics60
Keystone: Gift of Life76
Keystone: Emergency Department66
MI STA*AR (Rehospitalization Project)27

Slide 5

 Collaboration

Collaboration

MHA PSO:

  • Data analytics.
  • Psychological safety.
  • Education & training.
  • Tools to improve patient safety.

MHA Keystone:

  • Address patient safety.
  • Enhance coordination of care.
  • Work towards healthy unit culture.
  • Improve communication and teamwork.

Slide 6

 CUSP

CUSP

  • The Johns Hopkins Comprehensive Unit-Based safety program.
  • An intervention to learn from mistakes and improve safety culture.
  • Designed to integrate safety practices into a unit.
  • The framework for improving patient safety for MHA Keystone collaboratives.
  • 5 Step Process.

Provonost J Patient Safety 2005

Slide 7

 CUSP Steps

CUSP Steps

  • Step 1: Safety Culture Assessment (& Reassessment).
  • Step 2: Science of Safety Training.
  • Step 3: Staff Identify Defects.
  • Step 4: Executive Partnership.
  • Step 5: Learning from Defects/Tools.

Slide 8

 Step 1: Base Line Safety Culture Assessment

Step 1: Base Line Safety Culture Assessment

  • What: establish a baseline measure of Culture of Safety at the unit level.
  • Goal: assess the level of importance a unit/clinical area places on safety and elicit caregiver attitudes.
  • MHA PSO Role: generate a comprehensive picture of the unit/hospital through adverse event and cultural data analysis.

Slide 9

 Cultural Scores for MHA Keystone: Surgery 2008-2011

Cultural Scores for MHA Keystone: Surgery 2008-2011

Image: A bar chart labeled "How Healthy is Our Culture? Safety Attitudes Questionnaire Domain Scores" is shown.

Slide 10

 Cultural Domain Scores for MHA Keystone: Surgery 2008-2011

Cultural Domain Scores for MHA Keystone: Surgery 2008-2011

Image: Four bar charts labeled "Cultural Domain Scores for MHA Keystone" are shown. The two domains measured are teamwork and safety, for 2008 and 2011 in 31 hospitals.

Slide 11

 Adverse Events by Quarter for MHA Keystone: Surgery 2009

Adverse Events by Quarter for MHA Keystone: Surgery 2009

  • Q1: 14.
  • Q2: 24.
  • Q3: 19.
  • Q4: 18.

Facilities = 35

Slide 12

Step 2 Educate Caregivers About Patient Safety  

Step 2 Educate Caregivers About Patient Safety

  • What: Science of Safety Training.
  • Goals:
    • Inform staff about the magnitude of the patient safety program.
    • Provide a foundation for investigating safety hazards/defects from a systems perspective.
    • Highlight how they can make a difference in care safer.
  • MHA PSO Role: provide data support, literature review and "Evidence Library" of research from ECRI Wrong Site Surgery Tool Kit.

Slide 13

 Evidence Library

Evidence Library

  • Standards/Guidelines.
  • ECRI Institutes resources.
  • General Literature Review.
  • Lessons Learned.

Slide 14

 Step 3 Identification of Defects

Step 3 Identification of Defects

  • What: hospital staff identify defects.
  • Goal: tap into the expertise and knowledge of frontline staff to identify current risks to patient safety.
  • MHA PSO Role: provide a "safe" environment to encourage reporting of defects, help identify and prioritize issues.

Slide 15

 Adverse Event Contributing Factors for MHA Keystone: Surgery 2009

Adverse Event Contributing Factors for MHA Keystone: Surgery 2009

Image: A bar chart labeled "Adverse Event Contributing Factors for MHA Keystone: Surgery 2009" is shown.

Communication among staff members: 79
Availability of information: 29
Orientation & training of staff: 29
Care planning: 27
Other: 19
Adequacy of technological support: 17
Physical environment: 17
Equipment maintenance/management: 16
Patient identification process: 16
Physical assessment process: 16
Staffing levels: 16
Competency assessment/credentialing: 15
Communication with patient/family: 8
Supervision of staff: 7
Patient observation procedures: 5
Control of medications: 2

Facilities = 35
Factors = 326

Slide 16

Adverse Event Contributing Factors vs. Patient Safety Cultural Domains MHA Keystone: Surgery 2009  

Adverse Event Contributing Factors vs. Patient Safety Cultural Domains MHA Keystone: Surgery 2009

Image: A bar chart labeled "Surgical Adverse Event Contributing Factors" is shown.

Average % PositiveSafety ClimateTeam Climate
Communication (n=78)56%50%
Availability of Information (n=29)63%55%
Training of Staff (n=29)50%44%

Facilities = 31

Slide 17

 Step 4 Executive Partnership

Step 4 Executive Partnership

  • What: partners a senior hospital executive with a unit.
  • Goal: bridge the gap between senior leaders, middle management and frontline caregivers. Build the "business case" to executive.
  • MHA PSO Role: support executive understanding of significance of issues at unit level through data and research.

Slide 18

 Business Case Measures

Business Case Measures

How often did we find surgical checklist discrepancies?

  • OR Schedule Discrepancy.
  • Briefing/Debriefing Discrepancy.
  • Consent Discrepancy.
  • Documentation Discrepancy.

Image: To the right of the text is a bar chart.

Slide 19

Step 5 Learning From Defects and Applying Tools  

Step 5 Learning From Defects and Applying Tools

  • What: provides tools to improve teamwork, communication, and other systems of work in the unit.
  • Goal: learn from our mistakes, improve teamwork and communication.
  • MHA PSO Role: provide patient safety tools and resources to supplement the CUSP tools.

Slide 20

 Improvement Tools MHA PSO Contribution

Improvement Tools MHA PSO Contribution

  • ECRI Wrong Site Surgery Tool Kit:
    • Business Case.
    • Evidence Library.
    • Investigations.
    • Preventions.
    • Measuring/Monitoring.
    • Training.
  • RCA reviews.
  • Webinars.
  • Annual patient safety symposium.
  • Safe Tables.

Slide 21

 Improvement Tools Keystone Contribution

Improvement Tools Keystone Contribution

  • Learning From Defects Tool.
  • Briefings/Debriefings.
  • Shadowing.
  • Staff Safety Assessment.
  • Team Check Up Tool (with PSO).
  • Patient Safety Score Card (with PSO).

Slide 22

 Results

Results

  • The combination of MHA PSO and MHA Keystone resources greatly improves the ability to make a positive and sustainable impact on patient safety.
  • MHA Membership (Hospitals) understand and support the roles.
Current as of March 2012
Internet Citation: Using CUSP as a Framework for Improving Patient Safety (Text Version). March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/levy2/index.html