Learn Module Alternate Text

Slide Number and TitleSlide ContentContent for Alternative Text (Illustration)
Slide 1
Cover Slide
(CUSP Toolkit logo)The ‘Learn About CUSP’ module of the Comprehensive Unit-based Safety Program (CUSP) Toolkit. The CUSP toolkit is a modular approach to patient safety, and modules presented in this toolkit are inter-connected and are aimed at improving patient safety. 
Slide 2
Learning Objectives
  1. Show how CUSP supports other quality and safety tools
  2. Describe Comprehensive Unit-based Safety Program (CUSP) framework and the goals of the CUSP Toolkit
  3. Demonstrate how to apply the CUSP Toolkit in a clinical environment
  4. Review the impact of errors and patient harm and the underlying causes of errors
  1. Show how CUSP supports other quality and safety tools
  2. Describe Comprehensive Unit-based Safety Program (CUSP) framework and the goals of the CUSP Toolkit
  3. Demonstrate how to apply the CUSP Toolkit in a clinical environment
  4. Review the impact of errors and patient harm and the underlying causes of errors
Slide 3
CUSP Supports
Kotter’s Eight Steps of Change2
KotterCUSP Toolkit Modules
Step 1: Create a sense of urgencyUnderstand the Science of Safety
Step 2: Create a guiding coalitionAssemble the Team
Engage the Senior Executive
Step 3: Develop a shared visionIdentify Defects Through Sensemaking
Step 4: Communicate the visionUnderstand the Science of Safety
Identify Defects Through Sensemaking
The modules of the CUSP Toolkit all support steps in the Kotter change model.
Kotter's concept of ‘Create a sense of urgency’ links to the CUSP module ‘Understand the Science of Safety’
Kotter's concept of ‘Create a guiding coalition’ links to the CUSP modules ‘Assemble the Team’ and ‘Engage the Senior Executive’
Kotter's concept of ‘Develop a shared vision’ links to the CUSP module ‘Identify Defects Through Sensemaking’
Kotter's concept of ‘Communicate the vision’ links to the CUSP modules ‘Understand the Science of Safety’ and ‘Identify Defects Through Sensemaking’ TeamSTEPPS logo and penguin
Slide 4
CUSP Supports
Kotter’s Eight Steps of Change2
KotterCUSP Toolklit Modules
Step 5: Empower others to actAssemble the Team
Identify Defects Through Sensemaking
Implement Teamwork and Communication
Step 6: Generate short term winsImplement Teamwork and Communication
Step 7: Consolidate gains and produce more changeIdentify Defects Through Sensemaking
Step 8: Anchor new approaches in cultureUnderstand the Science of Safety
Implement Teamwork and Communication
Kotter's concept of ‘Empower others to act’ links to the CUSP modules ‘Assemble the Team,’ ‘Identify Defects Through Sensemaking,’ and ‘Implement Teamwork and Communication’
Kotter's concept of ‘Generate short term wins’ links to the CUSP module ‘Implement Teamwork and Communication’
Kotter's concept of ‘Consolidate gains and produce more change’ links to the CUSP module ‘Identify Defects Through Sensemaking’
Kotter's concept of ‘Anchor new approaches in culture’ links to CUSP modules ‘Understand the Science of Safety’ and ‘Implement Teamwork and Communication’ TeamSTEPPS logo and penguin
Slide 5
CUSP Aligns With and Supports
Other Quality and Safety Tools1
  • TeamSTEPPS®
  • Six Sigma
  • Institute for Healthcare Improvement Model for Improvement
  • Plan-Do-Study-Act
  • Root Cause Analysis
  • Failure Mode Effect Analysis
TeamSTEPPS penguin and logo
Slide 6
CUSP is Compatible with
TeamSTEPPS3
TeamSTEPPS StepCUSP Toolkit Modules
Step 1. Create a change team.Assemble the Team
Engage the Senior Executive
Step 2. Define the problem.Identify Defects Through Sensemaking
Understand the Science of Safety
Step 3. Define the aims.Identify Defects Through Sensemaking
Step 4. Design an intervention.Identify Defects Through Sensemaking Understand the Science of Safety
The CUSP Toolkit modules are compatible with TeamSTEPPS.
TeamSTEPPS 1. ‘Create a change team’ links to CUSP modules ‘Assemble the Team’ and ‘Engage the Senior Executive’
TeamSTEPPS 2.’ Define the problem’ links to CUSP modules ‘Identify Defects through Sensemaking’ and ‘Understand the Science of Safety’
TeamSTEPPS 3. ‘Define the aims’ links to the CUSP module ‘Identify Defects through Sensemaking’
TeamSTEPPS 4. ‘Design an intervention’ links to CUSP modules ‘Identify Defects Through Sensemaking’ and ‘Understand the Science of Safety’ TeamSTEPPS logo and penguin
Slide 7
CUSP is Compatible with
TeamSTEPPS3
TeamSTEPPS StepCUSP Toolkit Modules
Step 5. Develop a plan for testing the effectiveness.Identify Defects Through Sensemaking
Step 6. Develop an implementation plan.Engage the Senior Executive
Identify Defects Through Sensemaking Understand the Science of Safety
Step 7. Develop a plan for sustained improvement.Understand the Science of Safety
Step 8. Develop a communication plan.Assemble the Team
Engage the Senior Executive
Identify Defects Through Sensemaking
TeamSTEPPS 5. ‘Develop a plan for testing the effectiveness’ links to the CUSP module ‘Identify Defects Through Sensemaking’
TeamSTEPPS 6. ‘Develop an implementation plan’ links to CUSP modules ‘Engage the Senior Executive,’ ‘Identify Defects Through Sensemaking,’ and ‘Understand the Science of Safety’
TeamSTEPPS 7. ‘Develop a plan for sustained improvement’ links to the CUSP module ‘Understand the Science of Safety’
TeamSTEPPS 8. ‘Develop a communication plan’ links to CUSP modules ‘Assemble the Team,’ ‘Engage the Senior Executive,’ and ‘Identify Defects Through Sensemaking’ TeamSTEPPS logo and penguin
Slide 8
Is Your Hospital Safe?
  • Would you want a loved one to be a patient at your hospital? Your unit?
  • Would you want to be a patient in the unit where you work?
  • Can you say with 100 percent certainty that you believe that your hospital does everything it can to protect its patients?
A patient in a hospital bed surrounded by a family member and two clinicians.
Slide 9
Video
 Video icon
[HRET will insert alt text once video is inserted]
Slide 10
The CUSP Model
  • Created through a collaborative effort of the Agency for Healthcare Research and Quality and state and national-level innovators in patient safety
  • Dovetails with, and supports, a range of quality and safety improvement models
  • Encompasses a wide range of safety tools and approaches
  • Based on the understanding that all culture is local, and that work to improve culture must be owned at the unit level
  • Believes that harm is not an acceptable ‘cost of doing business’
  • Can be applied by anyone, anywhere
 
Slide 11
A Collaborative Effort4
  • Teams at the Johns Hopkins Quality and Safety Research Group originally developed the CUSP model with funding from the Agency for Healthcare Research and Quality
  • An infection reduction project of the Michigan Health and Hospital Association Keystone Center for Patient Safety and Quality proved that CUSP was successful
  • The Health Research & Educational Trust of the American Hospital Association led On the CUSP: Stop BSI and other national projects to apply the CUSP model
  • The CUSP Toolkit using Kotter’s change model combines the CUSP model, with existing frameworks like TeamSTEPPS, Just Culture, and others to provide complete tools to support units in improving culture
 
Slide 12
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
  Note:After a unit’s first implementation of CUSP, modules can be used in any order, depending on the needs of the unit or organization.
 
Slide 13
Toolkit Users
  • Senior executives
    • Help leaders prioritize improvement efforts
    • Provide resources for interventions to alleviate defects
  • Patient safety officers
    • Work with senior executives and managers to maintain an ongoing infrastructure for improvement activities
  • Nurse managers
    • Educate staff on the science of safety
    • Provide opportunities for staff to learn and practice using teamwork and communication tools
    • Work with senior executives and managers to maintain an ongoing infrastructure for improvement activities
 
Slide 14
Toolkit Users
  • Frontline staff
    • Engage with Stakeholders in safety improvement
  • Physician champions
    • Share knowledge on the immediate and long-term benefits of teamwork and communication tools
 
Slide 15
Implementation
  • Share videos with teams to spark engagement in staff safety assessments
  • Provide templates and discussion guides to project leads
  • Educate teams on the science of safety
  • Use videos and training modules to orient new clinical staff
  • Train teams in using teamwork and communication tools
  • Engage senior executives and physician champions
 
Slide 16
Challenges
  • Applicability and usability of CUSP within specialty units (i.e. NICU, oncology)
  • Senior executive engagement and participation
  • High staff turnover
  • Nurse empowerment
 
Slide 17
Assemble the Team
  • Understand the importance of your CUSP team
  • Develop a strategy to build a successful team
  • Identify characteristics of effective teams and barriers to team performance
  • Define roles and responsibilities of team members
Team members standing together.
Slide 18
Barriers to Team Performance3
  • Inconsistency in team membership
  • Lack of time
  • Lack of information sharing
  • Hierarchy
  • Varying communication styles
  • Presence of conflict
  • Lack of coordination and follow-up
  • Misinterpretation of cues
  • Lack of role clarity
Team member standing before a brick wall.
Slide 19
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 next to each other.
Slide 20
The Challenges of Partnering with a
Senior Executive
  • May lack clinical background
  • May not recognize the value of CUSP
  • May not be able to meet with the CUSP team regularly
 
Slide 21
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 teamwork
  • Indicate how teams make wise decisions when there is diverse and independent input
Team members standing next to a line cart.
Slide 22
System-Level Factors Impact Safety5
  • Institutional
  • Hospital
  • Departmental Factors
  • Work Environment
  • Team Factors
  • Individual Provider
  • Task Factors
  • Patient Characteristics
Concentric circles show the layered factors of patient safety. Institutional factors, hospital factors, departmental factors, work environment factors, team factors, individual provider factors, task factors, and patient characteristics all have an effect on patient safety.
Slide 23
Identify Defects Through Sensemaking
  • Introduce CUSP and Sensemaking tools to identify defects and errors
  • Discuss the relationship between CUSP and Sensemaking
  • Show how to apply CUSP and Sensemaking tools
  • Discuss how to share findings
Note: This module combines the CUSP steps Identify Defects and Learn from Defects
Team members standing around a wall chart.
Slide 24
Examples of Defects or Errors That
Affect Patient Safety
DefectIntervention
Unstable oxygen tanks on bedsOxygen tank holders repaired or new holders installed institution wide
Medication look-alikeEducation conducted, medications physically separated, and letter sent to manufacturer
Missing equipment on cartChecklist developed for stocking cart
Inconsistent use of Daily Goals rounding toolConsensus reached on required elements of Daily Goals rounding tool
Inaccurate information by residents during roundsElectronic progress note developed
The table presents a series of defects and their interventions:
  1. Unstable oxygen tanks on beds resulted in an intervention in which oxygen tank holders were repaired or new holders were installed across the institution.
  2. A medication look-alike incident led to an intervention in which education was conducted, medications were physically separated, and letters were sent to the manufacturer.
  3. Missing equipment on a cart resulted in the development of a checklist for stocking the cart.
  4. The inconsistent use of Daily Goals during rounding resulted in a group consensus on required elements of the Daily Goals rounding tools.
  5. Inaccurate information by residents during rounds resulted in the development of an electronic progress note.
Slide 25
Implement Teamwork and
Communication
  • Recognize the importance of effective communication
  • Identify barriers to communication
  • Describe the connection between communication and medical error
  • Identify and apply effective communication strategies from CUSP and TeamSTEPPS
TeamSTEPPS logo and penguin
Slide 26
Elements That Affect Communication and
Information Exchange
  • Interruptions
  • Task absorption
  • Verbal abuse
  • Fatigue
  • Not following plan of care
  • Ambiguous orders or directions
  • Change in team members
  • Work load
 
Slide 27
Apply CUSP
  • Introduce Just Culture principles
  • Learn how Just Culture principles can augment CUSP
  • Review key steps of the CUSP Toolkit
A Just Culture system6
  • Holds itself accountable
  • Holds staff members accountable
  • Has staff members that hold themselves accountable
Team members standing together.
Slide 28
The CUSP Model Generates
Measurable Results7
  • CUSP in Michigan ICUs
  • Correlated with significant improvements in safety climate in 71 units
  • Overall mean safety climate scores significantly improved from 42.5 percent (2004) to 52.2 percent (2006)
  • In 2009, more than 350 hospitals in 22 States reduced CLABSI rates by an average of 35 percent after implementing CUSP
 
Slide 29
CUSP Results
  • Heightened engagement of staff and senior leaders
  • Improved communication among care team members
  • Shared mental models
  • Expanded knowledge of potential
    hazards and barriers to safety
  • Collaborative focus on systems of care
An arrow sweeping upward to depict CUSP results that build on each other.
Slide 30
Summary
  • CUSP integrates with and supports a broad range of quality and safety models
  • Communication is cited as a root cause of most errors
  • Individuals across an organization can use the CUSP Toolkit and expect measurable results
 
Slide 31
References
  1. Agency for Healthcare Research and Quality, Department of Defense. TeamSTEPPS. Available at http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.html
  2. Kotter J, Rathgeber H.Our iceberg is melting: Changing and succeeding under any conditions: 1st ed. New York, St. Martin's Press; 2006.
  3. Agency for Healthcare Research and Quality, Department of Defense. TeamSTEPPS.  Available at http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.html
  4. Health Research and Educational Trust, Johns Hopkins University Quality and Safety Research Group, Michigan Health & Hospital Association Keystone Center for Patient Safety and Quality.  Eliminating CLABSI: A national patient safety imperative a progress report on the National On the CUSP: Stop BSI project. Rockville, MD; Agency for Healthcare Research and Quality, April 2011. AHRQ Publication No: 11-0037-EF.
 
Slide 32
References
  1. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154–7.
  2. Griffith, S. Just Culture. Plano, TX: Outcome Engineering; 2011.
  3. Pronovost P, Goeschel C, Colantuoni E, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ. 2010;340:c309.
 
Page last reviewed April 2013
Internet Citation: Learn Module Alternate Text. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/learn/learnalttext.html