Prepared for:
Agency for Healthcare Research and Quality (AHRQ)
U.S. Department of Health and Human Services
Contract Number: HHSA2902010000251/HHSA29032000IT, Task Order #1
Prepared by: Artemis March, M.B.A., Ph.D. for the Health Research & Educational Trust (HRET)
September 28, 2012
Contents
Acknowledgements
About This Guide
What Is CUSP?
How To Learn More About CUSP With the CUSP Toolkit
Peterson Regional Medical Center
Organizational and Cultural Context
Vascular Access Team
CLABSI Team
CUSP Team
CUSP in Practice
Critical Moments
NorthCrest Medical Center
Organizational and Cultural Context
Critical Moments
Integrating CUSP With Another Improvement System
CUSP
Shore Health System
Target Zero: Senior Leadership, Planning, and Launch
Organizational and Cultural Context
Performance Improvement Teams
Spreading Ownership
CUSP
Critical Moments
Ingrain, Sustain, Expand
Saint Joseph Mercy Health System–Ann Arbor
Keystone ICU Project
Saint Joe's ICUs
Keystone Team
CLABSI Elimination Process
Going House-Wide
CUSP and the Culture of Safety
Expanding Scope
Sepsis
Critical Moments in Culture Change
What Do These Stories Tell Us?
Persistent Leadership Engagement
Engaged Leaders and Champions
Getting to Zero Is Possible
Culture Matters
All Staff Must Own Safety
All Staff Must Be Empowered
Learning Organizations Are Safer
Acknowledgements
HRET gratefully acknowledges the insights provided by the following CUSP team members who were interviewed by Artemis March, M.B.A., Ph.D., for this guide.
NorthCrest Medical Center, Springfield, Tennessee
Angie Beard, R.N., M.S.N., Chief Nursing Officer and Vice President of Professional Services
Randy Davis, CIO and Senior Vice President for Performance Improvement
Scott Raynes, President and CEO
Peterson Regional Medical Center, Kerrville, Texas
Kaeli Dressler, R.N., M.S.N., NEA-BC, Chief Nursing Officer
Theresa Hickman, R.N., ICU Nurse, Nurse Educator
Angela Hons, R.N., ICU Nurse
William Morris, M.D., Physician Quality Advisor
Aaron Saul, R.N., former ICU Nurse, PICC/IV Infusion Clinical Supervisor
Barbara Stehling, Director of Quality Services
Shore Health System, Easton and Cambridge, Maryland
Julie Bryan, R.N., CIC, Infection Prevention Coordinator
Rob Carroll, M.B.A., Director of Performance Measurement and Improvement
Christopher Parker, R.N., M.S.N., Chief Nursing Officer and Senior Vice President for Professional Services
Michael Tooke, M.D., Chief Medical Officer and Senior Vice President
Saint Joseph Mercy Health System, Ann Arbor, Michigan
Toy Bartley, R.N., M.S.N., MICU Clinical Nurse Leader
Christine Curran, M.D., MICU Medical Director
Denise Harrison, R.N., M.S.N., Director of Critical Care
Pat Posa, R.N., M.S.A., System Performance Improvement Leader
Mary-Anne Purtill, M.D., SICU Medical Director
