Apply Module Alternate Text

Slide Number and TitleSlide ContentContent for Alternative Text (Illustration)
Slide 1
Cover Slide
(CUSP Toolkit logo)The “Apply CUSP” module of the CUSP Toolkit. The CUSP toolkit is a modular approach to patient safety, and modules presented in this toolkit are interconnected and are aimed at improving patient safety.
Slide 2
Learning Objectives
  • Introduce Just Culture principles
  • Learn how Just Culture principles can augment CUSP
  • Review key steps of the CUSP Toolkit
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Slide 3
Introduction to Just Culture Principles
Slide titleSlide title
Slide 4
Understand Just Culture
(vignette still)Video icon
Slide 5
Just Culture1
  • A system that:
    • Holds itself accountable
    • Holds staff members accountable
    • Has staff members that hold themselves accountable
A patient in a hospital bed surrounded by the health care team.
Slide 6
Understanding Risk and Human Behavior1
  • Human Error:
    • Inadvertently completing the wrong action; slip, lapse, mistake
  • At-Risk Behavior
    • Choosing to behave in a way that increases risk where risk is not recognized, or is mistakenly believed to be justified
  • Reckless Behavior
    • Choosing to consciously disregard a substantial and unjustifiable risk
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Slide 7
Managing Error and Risk1
  • Human Error
    Product of our current system design and behavioral choices

Manage through changes in:

  • Choices
  • Processes
  • Procedures
  • Training
  • Design
  • Environment

Console

  • At-Risk Behavior
    A choice: risk believed insignificant or justified

Manage through:

  • Removal of incentives for at-risk behaviors
  • Creation of incentives for healthy behaviors
  • Situational awareness

Coach

  • Reckless Behavior
    Conscious disregard of substantial and unjustifiable risk

Manage through:

  • Remedial action
  • Punitive action
    Punish

The three behaviors are human error, at-risk behavior and reckless behavior.

Human error is the product of our current system design and behavioral choices. It is managed through changes in choices, processes, procedures, training, design and the environment. Consolation is the appropriate response to human error.

At-risk behavior is a choice made while believing that the risk is insignificant or justified. This behavior is best managed through removing incentives for at-risk behaviors, creating incentives for healthy behaviors, and increasing situational awareness. Coaching is the best response to at-risk behavior.

Reckless behavior is the conscious disregard of substantial and unjustifiable risk. It is managed through remedial and punitive actions.

Punishment is the appropriate response to reckless behavior.

Slide 8
Systems and Behaviors Work Together To Improve Outcomes1
  • System Design
  • Mission, Values, and Expectations
  • Behavioral Choices
  • Improved Outcomes
  • Learning Systems
  • Accountability and Justice
Both system design and behavioral choices have an effect on patient safety. Learning systems, like mission, values, and expectations, affect system design and in turn, behavioral choices. These inputs also influence the accountability and justice of the environment to bring about improved outcomes.
Slide 9
Peer to Peer Coaching
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Slide 10
Engineering System Design to Support Behavior Choices1
  • Punitive Culture: Transparency is impossible
  • Blame-Free Culture: No accountability
  • Just Culture: Optimally supports a system of safety
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Slide 11
Leadership Team's Role in Applying Just Culture Principles
  • Have a procedure in place for employees to follow
  • Ensure employees are properly trained
  • Offer positive reinforcement at the monthly Learning from Defects meeting
Two senior executives standing next to each other.
Slide 12
Debrief on Accountability
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Slide 13
CUSP Toolkit Review
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Slide 14
CUSP Toolkit Modules
  • Learn About CUSP
  • Assemble the Team
  • Engage the Senior Executive
  • Understand the Science of Safety
  • Identify Defects Through Sensemaking
  • Implement Teamwork and Communication
  • Apply CUSP
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Slide 15
Assemble the Team
  • Address the importance of the CUSP team
  • Develop a strategy to build a successful team
  • Identify characteristics of successful teams and barriers to team performance as identified in TeamSTEPPS
  • Define roles and responsibilities of CUSP team
Team members standing together.
Slide 16
Keys to Assembling the Team
  • Understands that patient safety culture is local
  • Composed of engaged frontline providers who take ownership of patient safety
  • Includes staff members who have different levels of experience
  • Tailored to include members based on clinical intervention
  • Meets regularly (weekly or at least monthly)
  • Has adequate resources
 
Slide 17
Engage the Senior Executive
  • Identify characteristics to search for when recruiting the senior executive
  • Describe the responsibilities of the senior executive
  • Explain the role of the senior executive in addressing technical and adaptive work
  • Explain how to engage the senior executive and develop shared accountability for the work
Two senior executives standing together.
Slide 18
Keys to Engaging the Senior Executive
  • Acknowledge the senior executive's perspective (“What's in it for me?”)
  • Increase the visibility of your senior executive
  • Ensure a senior executive is assigned to each CUSP team and participates regularly in meetings
  • List identified safety issues in the Safety Issues Worksheet for Senior Executive Partnership or a tracking log
A provider and a senior executive standing next to each other.
Slide 19
Understand the Science of Safety
  • Describe the historical and contemporary context of the science of safety
  • Explain how system design affects system results
  • List the principles of safe design and identify how they apply to technical work and team work
  • Indicate how teams make wise decisions when there is diverse and independent input
Team members examining an x-ray image.
Slide 20
Keys to Understanding the Science of Safety
  • Develop a plan so all staff on your unit view the Understand the Science of Safety video
  • Video screening should be mandatory for all unit staff
  • Create a list of who has watched the video
  • Describe the three principles of safe design:
  • Standardize
  • Create independent checks
  • Learn from defects
Team members in a conference room watching a video.
Slide 21
Identify Defects Through Sensemaking
  • Introduce CUSP and Sensemaking tools to identify defects or errors
  • Discuss the relationship between CUSP and Sensemaking
  • Show how to apply CUSP and Sensemaking tools
  • Discuss how to share findings
Team members discussing a patient's fall after slipping on water left on a hallway floor.
Slide 22
Keys to Identifying Defects Through Sensemaking
  • CUSP and Sensemaking share several common themes
  • CUSP and Sensemaking tools help teams identify defects and identify ways to deter them from occurring in the future
  • The team should:
  • Share summaries of defects within the organization
  • Engage staff in conversations to enhance Learning from Defects
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Slide 23: Implement Teamwork and Communication2
  • Recognize the importance of effective communication
  • Identify barriers to communication
  • Describe the connections between communication and medical error
  • Identify and apply effective communication strategies from CUSP and TeamSTEPPS®
The communication that takes place between two people risks exposure to many roadblocks between its transmission from one individual to another. First, the message is encoded, or created, by the sender, who then transmits the message to the receiver, who then must decode, or process, the message. While the message is being transmitted, it may be exposed to barriers that may muddy the context and clarity of the message as it is sent and received.
Slide 24: The Keys to Effective Communication3
  • Complete
  • Clear
  • Brief
  • Timely
TeamSTEPPS logo and penguin
Slide 25: Summary
  • A Just Culture is a system that holds itself accountable, holds staff members accountable, and has staff members who hold themselves accountable.
  • A Just Culture environment is ruled by both transparency and accountability and supports improved outcomes by emphasizing both robust systems and appropriate behaviors.
  • Use the Just Culture principles along with the CUSP principles involved when assembling the team, engaging the senior executive, identifying defects through Sensemaking, and employing teamwork and communication.
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Slide 26
References
  • Griffith, S. Just Culture. Plano, TX: Outcome Engineering; 2011
  • (Adapted from) Dayton E, Henricksen K. Communication failure: basic components, contributing factors and the call for structure. Joint Commission Journal. 2007;33(1):36.
  • Agency for Healthcare Research and Quality. TeamSTEPPS Fundamentals Course: Module 6 Communication. http://teamstepps.ahrq.gov/abouttoolsmaterials.htm Accessed August 18, 2011.
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Page last reviewed March 2013
Internet Citation: Apply Module Alternate Text . March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/apply/applyalttext.html