Organizational Embrace of CUSP to Improve Patient Safety (Slide Presentation)

On the CUSP: Stop BSI

This PowerPoint slide presentation was shown on March 20, 2012.

 Contents

Slide 1. The Organizational Embrace of CUSP to Improve Patient Safety
Slide 2. Objectives
Slide 3. Speakers
Slide 4. Holy Cross Hospital
Slide 5. Agenda
Slide 6. Holy Cross Hospital
Slide 7. HCH Patient Safety Initiatives
Slide 8. December 2010 AHRQ Survey
Slide 9. Fall 2010
Slide 10. CUSP
Slide 11. Selecting CUSP Teams
Slide 12. April 2011
Slide 13. CUSP Teams
Slide 14. Image
Slide 15. CUSP Team Activities
Slide 16. Learning From Defects
Slide 17. Directed Defects Work
Slide 18. Projected Time for PSL
Slide 19. CUSP All Teams Meeting
Slide 20. Interventional Radiology CUSP
Slide 21. Sustaining CUSP
Slide 22. Focusing Our Organizational Efforts
Slide 23. Organizational Initiatives
Slide 24. Resilience
Slide 25. Connecting the Dots
Slide 26. Upper Chesapeake Health, Maryland
Slide 27. Upper Chesapeake Health, Maryland
Slide 28. Senior Leadership Commitment
Slide 29. Senior Leadership Commitment
Slide 30. Our Journey
Slide 31. Our Journey
Slide 32. Flexibility is a Necessity
Slide 33. Current Process
Slide 34. Accountability-The Grid
Slide 35. Sample Walkabout Grid
Slide 36. Walkabout Agenda
Slide 37. Final Thoughts.
Slide 38. Questions.

 

Slide 1. The Organizational Embrace of CUSP to Improve Patient Safety

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March 20, 2012

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Slide 2. Objectives

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  • To relate an organization’s approach to implementing CUSP in multiple areas of the hospital to reduce harm beyond CLABSI and CAUTI and to improve the overall culture of safety
  • To discuss the mechanics at the hospital level of standing up and supporting CUSP teams

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Slide 3. Speakers

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Holy Cross Hospital Silver Spring, Maryland
Yancy Phillips, MD, MACP, Vice President Quality and Care Management
Sean Maxwell, Lead Angiography Technician

Upper Chesapeake Health Havre de Grace and Bel Air, Maryland
Jim Hursey, MBA, Sr. VP, COO
Judi Webster, RN, BSN, PI Patient Safety Coordinator

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Slide 4. Holy Cross Hospital

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CUSP Beyond the ICU 

Holy Cross Hospital
Silver Spring, Maryland

Yancy Phillips, MD, MACP, Vice President Quality and Care Management
Sean Maxwell, Lead Angiography Technician

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Slide 5. Agenda

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  • A little about us
  • CUSP teams as the lever
  • HCH CUSP team approach
  • Interventional radiology CUSP
  • Resilience
  • Connecting the dots

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Slide 6. Holy Cross Hospital

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  • Member of Trinity Health
  • Largest hospital in MD-DC suburbs:
    • Founded 1963
    • Primarily serves Montgomery and Prince George’s counties
    • Montgomery County’s only teaching hospital for medical education
    • 455 licensed beds, including 46 in the NICU
    • 1,321 medical staff and 3,062 employees
    • FY11 annual discharges: 33,210
      • Outpatient registrations: 170,317
      • Surgeries: 13,281
      • Emergency center: 88,121

Note: Image of Holy Cross Hospital is shown on the bottom right side of the slide.

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Slide 7. HCH Patient Safety Initiatives

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  • Perinatal Patient Safety Initiative
  • Stamp Out Sepsis campaign
  • Hiring experienced nurses
  • ICU multidisciplinary rounds
  • Mandatory influenza immunization
  • OR universal protocol
  • Patient Safety Committee
  • Root cause analysis, FMEA
  • Fall prevention
  • Etc., etc., etc.

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Slide 8. December 2010 AHRQ Survey

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Image of several charts showing Holy Cross's results from the 2010 AHRQ Survey on Patient Safety Culture and the 12 dimensions.

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Slide 9. Fall 2010

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  • Duke Patient Safety Course
  • December 2010 AHRQ Survey
  • Maryland Hospital Association
    • CLABSI-CUSP Collaborative
  • Make CUSP teams the tool
  • Invite Bryan Sexton to Holy Cross

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Slide 10. CUSP

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  • Focus on local processes and “defects of care”
  • Frontline patient safety leader
  • Area manager
  • Physician champion
  • Executive partner
    • Frontline staff
    • Other key personnel (e.g., RT in ICU)

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Slide 11. Selecting CUSP Teams

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  • CLABSI-CUSP Collaborative
    • SICU and ICU/CCU
  • Lower perception of safety scores
    • Pharmacy, Gen Surg, OR, Medicine, PCU, ER
  • Paired Units
    • IMC/CIC and HRP/L&D
  • Recent significant events
    • Interventional Radiology
  • Inpatient units without CUSP Teams
    • Joint & Spine, Women’s Surgery, Oncology, ASD
    • Maternity, NICU, Peds, Observation

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Slide 12. April 2011

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  • Three-day patient safety training – 94 individuals
  • Five one-hour frontline staff patient safety sessions
  • Grand rounds on patient safety
  • Medical Executive Committee dinner
  • “Safety as a System” video at orientation and on HCH intranet

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Slide 13.  CUSP Teams

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11 CUSP Teams representing
14 units and 68% of frontline staff

Surrounding the text are the names of the 11 teams.

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Slide 14. Image

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Image of a table showing the results of the AHRQ Patient Safety Culture survey comparing December 2010 and June 2011.

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Slide 15. CUSP Team Activities

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  • Team meets 1-2 times per month
  • Separate Executive Rounds with patient safety leader (PSL)
  • Work on a few defects at a time
    • Hand hygiene
    • Hand offs and transitions in care
    • Patient identification
    • Standardization of care practices
    • Supplies and equipment
    • Orders management
  • Protected time for patient safety leader
  • CUSP All Teams Meeting

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Slide 16. Learning From Defects

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  • What happened?
    • Brief defect description
  • Why did it happen?
    • System factors; e.g., staffing, workload, equipment, production pressure, training, fatigue, physical environment, etc.
  • What can we do to reduce the risk of it recurring with different caregivers?
  • How will we know the risk was reduced?
  • With whom should we share our learning?

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Slide 17. Directed Defects Work

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  • Hand hygiene
    • One hour per month “secret shopper” from each patient safety leader for three months
  • CLABSI — Critical care units
  • CAUTI — Med/surg units
  • CLABSI/VAP/CAUTI defects tool — ICUs

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Slide 18. Protected Time for PSL

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  • Budgeted up to 12 hours per month
    • Charged to patient safety
  • Schedule with manager
  • Have a plan for the time
    • Shadowing on unit
    • Shadowing off unit
    • Direct observation
    • Peer interviews
    • Defects of care
    • Data collection
  • Send summary of day’s activity to Dr. Phillips

To the left of the list is a bar chart showing Patient Safety Leader Hours Dedicated to CUSP Teams. 2012 Quarter 1 is 45.6 hours and 2012 Quarter 2 is 164.9 hours.

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Slide 19. CUSP All Teams Meeting

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  • Bimonthly at two different times and days
  • PSLs, managers, and physicians
  • Review tools and reports
  • Review protected time use
  • Share experiences and barriers

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Slide 20. Interventional Radiology CUSP

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  • Medication errors
    • Emphasize double verification
    • Direct observation
    • High alerts meds JIT
  • Outdated devices
    • Inventory label alert
    • Double confirmation
  • Consents
  • Protected time

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Slide 21. Sustaining CUSP

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  • Maturing Patient Safety Leaders (PSLs)
  • Using protected time Protecting the CUSP charter
  • Engaging physicians and executives
  • Using the tools without a CUSP team
  • Chartering new CUSP teams
  • Training new team members
  • Keeping organizational focus

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Slide 22. Focusing Our Organizational Efforts

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  • Key outcomes
    • Actively engaged staff
    • Overall perception of safety
  • Key drivers
    • Communication openness
    • Staff burnout

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Slide 23. Organizational Initiatives

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  • CUSP teams
  • Staff retention and performance
    • Pay structure and clinical ladder
    • Decreased agency
  • Web-based error reporting system
  • Just Culture principles
  • Resilience Resource Team

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Slide 24. Resilience

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  • Ability to recover from or adjust easily to misfortune or change
    Ability to become strong, healthy, or successful again after something bad happens
  • 4 F’s: friends, family, faith, fitness
  • Resilience Resource Team
    • Identify, organize, and communicate about existing resources to combat burnout
    • Develop new initiatives that increase resilience

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Slide 25. Connecting the Dots

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A diagram that shows that just culture, open communication, CUSP Teams, resilience, actively engaged staff, and staff retention all contribute to patient safety. 

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Slide 26. Upper Chesapeake Health, Maryland

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Jim Hursey, MBA, Sr. VP, COO

Judi Webster, RN, BSN, PI Patient Safety  Coordinator

Below text are images of the two Upper Chesapeake Health healthcare facilities.

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Slide 27. Upper Chesapeake Health, Maryland

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  • Two acute care, not-for-profit hospitals -- Upper Chesapeake Medical Center in Bel Air and Harford Memorial Hospital in Havre de Grace, 30-40 miles northeast of Baltimore.
  • Affiliated with the University of Maryland Medical System
  • Total of 272 licensed beds and combined total of over 90,000 ED visits and 1,400 deliveries annually
  • Almost 3,000 team members and over 600 medical staff physicians

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Slide 28. Senior Leadership Commitment

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  • Establish the culture of safety
    • Senior leadership support is the key to success
    • Expectations set for leaders and team members
      • Patient safety incorporated into the culture of excellence philosophy and strategic plan
        • Starts in orientation of new team members
          • Josie King video for all TM
          • Science of safety video for clinical and security TM
      • Ensure administrative polices are in place to support a culture of safety and just culture
        • Stop the Line Policy

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Slide 29. Senior Leadership Commitment

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  • Facilitate improvements by providing resources
    • Support nonproductive time for participation in collaborative meetings, conference calls, education, and data gathering for frontline TM and leadership
  • Model behaviors important to the culture of safety
    • Support speak-up and provide nonthreatening environment
  • Participate in patient safety walkabouts and collaborative executive rounding
    • Listen to TMs

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Slide 30. Our Journey

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  • Started biannual patient safety “walkabouts” in the summer of 2010 in all departments and nursing units as part of the evidenced-based Patient Safety Initiative
    • Introduced the concept of patient safety walkabouts and presented short agenda of “hot topics”
    • To stimulate open discussion, we used the results of AHRQ Patient Safety Culture Survey completed in December 2009

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Slide 31. Our Journey

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  • CUSP:CLABSI Collaborative Project started November 2010, calling for monthly rounds in ICUs
    • Used staff safety assessment as the basis for initial talking points for senior leadership to create a less threatening environment
    • Open forum for discussion of concerns

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Slide 32. Flexibility is a Necessity

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  • Began by scheduling one hour in each ICU, at each facility, every month
    • Difficult for senior leaders’ scheduling
      • “Schedule-keeper” needs to understand the importance of making walkabouts a priority
    • 60 minutes is too long for all involved – Clinical TM could not be away from patients that long, senior leaders running to next meeting – very stressful for all

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Slide 33. Current Process

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  • Monthly ICU rounds
    • 30-minute sessions; can accomplish everything in about 20 minutes on the ICUs
  • Quarterly rounds to remainder of departments/nursing units
  • Invite all TM to participate – EVS, Dietary, Rehab, Respiratory and Vascular Access Team, etc., are encouraged to participate in walkabouts on the nursing units when they are there – dates and times advertised and sent to managers and directors for communication
  • All levels of leadership and PI Patient Safety Coordinator participate
  • Use a grid to track issues

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Slide 34. Accountability - The Grid

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  • Created a spreadsheet for each unit/department
  • PI Patient Safety Coordinator records all issues presented and maintains the grid
  • Leadership is assigned to follow up on the item, their VP notified
  • Target completion dates are assigned
  • Spreadsheet is emailed to all leaders for their follow up and posting in each unit/department TM common area
    • Some issues (process) are referred to Unit-Based Nurse Practice Councils or the larger Nurse Practice Council for resolution.
  • Leaders send updates for the spreadsheet as items/issues are resolved
  • Leaders responsible for communicating grid to TM

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Slide 35. Sample Walkabout Grid

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Image of a sample chart for health professionals to use to track patient safety issues.

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Slide 36. Walkabout Agenda

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  • Short agendas are good
    • We start with a topic that is a patient safety goal
    • Hot topics
    • Share stories
    • Review status of open issues from previous visits
    • Open Discussion of TM patient safety concerns
      • Listen to all concerns
      • Ask for solutions
        • Charge nurse phones & alarm fatigue
        • RRT Responders Medication Access

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Slide 37. Final Thoughts

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  • It’s a marathon, not a sprint
  • Find what works for you and your culture
  • Involve physician leadership
  • Value team members – they have lots of great ideas
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Slide 38. Questions

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Image of a large question mark in a circle.

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Current as of June 2013
Internet Citation: Organizational Embrace of CUSP to Improve Patient Safety (Slide Presentation): On the CUSP: Stop BSI. June 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/contentcalls/org_embrace-slides/orgembraceslides.html