Peterson Regional Medical Center's CEO Pat Murray came back from a Texas Hospital Association (THA) meeting in August 2010 intrigued by CUSP. He asked his Director of Quality Services how Peterson might best use the CUSP culture change model and explored potential projects with nursing leadership. Consensus converged around CLABSI. Theresa Hickman, RN, an ICU nurse, manager, and educator, was asked to lead its implementation because of her prior CUSP experience at another facility, her communication skills, and her passion for CUSP:
“The CUSP program is the most powerful thing that has ever come into health care. It has the most potential to do good for patients. It's not just the CLABSI, it's the culture work, getting doctors and nurses to collaborate with each other, allowing nurses to identify and fix any issue that could cause a patient harm, and having daily goals for patient care. It makes things safer for everyone.”
Organizational and Cultural Context
Peterson is a private, nonprofit, 124-bed, rural hospital that moved in 2008 to a new facility loaded with patient amenities. Nursing leadership gave input into the design of nursing units. Although he did not yet quite consider himself an evangelist for “healing design,” Murray acknowledged it had definitely improved safety and quality, and “makes a difference in how patients are cared for.”
At Peterson, nurses had long felt comfortable speaking out if safety was being compromised. Dr. William Morris, a Peterson internist since 1977, described the evolution in which nurse empowerment grew from being merely accepted to being expected. Nevertheless, some nurses, especially new graduates, lack the confidence and certainty to speak up. Morris said, “That's one of the things we are working on—letting nurses know they have the support of nursing administration, the general administration, and the Medical Executive Committee to be the safety net for any number of things.”
Vascular Access Team
Aaron Saul, RN, a highly regarded ICU nurse, began inserting peripherally inserted central catheter (PICC) lines in 2006. Based on literature review, connections with other innovators and his own experience, he began augmenting the CLABSI elimination bundle. He added detail on insertion and maintenance, including following up on lines, hub cleanings, and frequency of dressing changes. As fellow ICU nurse Angela Hons said, “Aaron drew from everywhere and made the bundle his own.”
The following year, Saul began to develop criteria for selecting the most appropriate line to best meet the patient's needs. This protocol considered patient diagnosis, length of stay, length of intravenous (IV) therapy, medication being infused, pH and osmolarity of that medication, and the patient's venous access history.
As PICC coordinator and then as PICC/IV infusion clinical supervisor, Saul responded to the radiologists' suggestion that he train nurses to insert PICC lines by developing a PICC team. They used his CLABSI bundle and rounded daily to monitor the lines and teach at the bedside. Late in 2010, the team broadened in scope and became a Vascular Access Team. Saul built a strong case for sometimes using a PICC line as opposed to using a major vessel, and for well-trained and mentored nurses doing vascular access work:
“If nurses like me are placing central lines, it frees up the surgeons who otherwise might be called by the ICU in the middle of a surgery and it stops interrupting radiologists. Doing lines right takes time. Nurses are trained to be meticulous, they learn the anatomy and veins, how to do the proper skin preparation, the full draping from head to toe, matching the size of the catheter to the vein. You have to pay attention to the details. If you miss one thing, you can start a cascade of events. You need to do it exactly the same way every time.”
Saul advocated for the CLABSI bundle to be adopted by any clinician who placed lines whether at the bedside, in surgery, in the ER, or in a radiology suite. He encountered both resistance and support among physicians. He found a champion in Morris who, for the past ten years, had combined his practice with quality improvement (QI) work at the hospital, most recently becoming a full-time quality consultant with the hospital. As the PICC team gradually did more and more of the insertions and physicians did fewer, physician involvement in insertion lessened while acceptance of the PICC team expanded.
In 2009, the Joint Commission established a national patient safety goal of preventing CLABSI. Barbara Stehling, now Director of Quality Services, took it to the PICC team for evaluation and to assess what else Peterson needed to do. “Our practice was already pretty much in place, but we needed to be tracking and documenting it.” A CLABSI team was formed. Members included Saul, an ICU nurse, the Director of Quality Services, and a quality analyst.
“CLABSI made the most sense,” Murray agreed. “We had a reasonably good track record, but could we still enhance or improve? Were our systems consistent with best practices? How could we be more consistent with the protocols we already had? How could we further engage the physicians?”
Peterson revised hospital policy and procedures in 2010 to standardize use of the central line insertion and maintenance bundles hospital-wide for any clinician inserting any venous access device. Because the PICC Team was already operating throughout the hospital, these policy and procedural changes did not represent a dramatic change, but gave a significant boost to its house-wide deployment.
Standard, in fact, meant mandatory for nurses because they were employees, whereas physicians were independent practitioners. “A couple of whom,” Morris said, “were tough to get on board.” Peterson has a history of “doing everything jointly. Nursing may initiate something, and the physician committees bless or fine tune it.” However, as he pointed out, “We don't pay them, we only give them privileges. We are a small town with a shortage of doctors. We do keep track of things, and if they have enough variation in outcomes, recredentialing is not automatic.” Sooner or later, resistors came around through peer pressure and one-on-one conversations with Morris.
Morris's indirect style of engaging physicians and sense of timing did not press or initiate discussion directly. Instead, during the course of a conversation, perhaps over lunch, he might bring out an article to share, “I wonder if you would like to read it,” or, “See what you think.” Morris was keenly aware that,
“Physicians resist being told what to do by quality people, the government, or core measures—especially if it's different from what they've been taught, but they are still scientists. I point out that they were also told in medical school, and this is what new physicians are being told. If they want to keep up, they might want to take a look.”
Once Peterson “hardwired” the CLABSI bundle into practice and sustained a CLABSI rate of zero, it was no longer necessary for the CLABSI team to meet regularly. Peterson sustained zero through the skills of the Vascular Access Team, adherence to the insertion and maintenance bundles, daily rounding, educating new nurses, bimonthly IV classes, choice of dressings, changing dressings every few days, and removing lines as soon as possible.
Peterson also educated their board about CLABSI. As Hickman summarized: “These are lay people on the board. What they needed to understand was that before, CLABSI was part of the price of doing business because we didn't know how not to have them. Now that we know how to prevent them, we do, so now we don't have any.”
Like many hospitals, Peterson was not collecting CLABSI rate data to know how far it has come. What it does know is that it has gone 32 months without a CLABSI anywhere in the hospital.
In September 2010, Peterson formed a CUSP team and conducted a safety culture survey that documented some of the hospital's communication issues. Hons noted, “When we started, it was to improve the ICU, but central lines involve the whole hospital. So it spilled over and evolved, even though not officially.”
Initially, Hickman and the ICU's Nurse Director led the CUSP Team. They told staff, “tell us where the potholes are, and we'll do something about it.” They encountered some skepticism because in the past, when problems had been reported, fixes followed too rarely. Kaeli Dressler, Chief Nursing Officer, also recognized that, “it was important to have quick successes and fast turnaround on items identified by staff. This also meant that directors had to become facilitators rather than try to fix things themselves.” Hickman elaborated, “CUSP starts out very leadership driven, but as you have successes and the staff themselves begin to fix things that are wrong, you see the sparkle light up their eyes, and it snowballs to being staff nurse-driven.” The CUSP process soon gained legitimacy and momentum.
As “Learning from Defects” and process changes became hardwired into practice, the team transitioned in May 2011 to being a peer-led, nurse-only group and no longer met formally but on an ad hoc basis to address problems as they arose on the floor. Hickman had observed, “When things are moving, problems raise their head. You need to catch them in motion.”
CUSP in Practice
Murray had hoped that the CUSP process would enhance skills such as teamwork and the confidence that “we could do it, too.” He thought that hearing stories of others who have walked similar walks would be more empowering than hearing about it from a quality committee. He was, therefore, gratified by the sense of engagement, empowerment and ownership he was picking up from staff in its wake. “While I can't say it's exclusively due to CUSP, there's a new sense of ownership about infections; it's my job, it's not just IP's anymore. We're in this together.” Hickman described some of her experience with CUSP:
“When I started this work, I thought safety was medical errors and falls, but it is so much larger than that. We must focus on the largeness of patient safety that is full of so many itty-bitty things that are defects and have the potential to cause patient harm. CUSP is a method that allows front line caregivers to tell you the little stuff, and it gets fixed—because they can mostly fix it themselves. There are no more workarounds.”
One of those “little things” arose when an ICU nurse made a drug error because the small vial packaging print was very difficult to read. Now there are magnifying glasses all over the ICU. Hickman noted, “When a defect comes back to you, you fix it better than you did before so it stays fixed.”
There is a CUSP communications book at the nurses' station, but one of Hickman's favorite modes of communication was to post fixes and important information in the staff bathroom. She said, “If I know it, you're going to know it. People come to our bathroom from other floors just to see what's going on.” Like Morris, she had developed effective ways of communicating with physicians. She didn't try to have a sit-down meeting, but was always prepared and got right to the point when she ran into one of them in the elevator, hallway, or parking lot. She also spoke to them privately.
Hickman elaborated on CUSP's effect on safety culture:
“It's much harder to deal with this big culture balloon and all the things inside of it—like people not talking with each other, not collaborating. Now with CUSP, you've got doctors and nurses and others talking to each other and collaborating. Once you get this culture thing going, then it's easier to take on other health care associated initiatives and get buy-in because people are already connected.”
Like Hickman, Morris was enthusiastic about how CUSP had enhanced nurse-to-nurse and nurse-doctor communication.
“CUSP gives us an objective process (Daily Goals) through which the nurses and the doctors involved discuss the patient's case on a daily basis—here are the expected outcomes for the day, and here is what is in fact going on. Good doctors have always done this well, and experienced nurses can get it out of the doctors, but CUSP gives new nurses a tool to get mumbling and tight-lipped physicians to tell them what they're thinking.”
Hons, who now co-leads the CUSP team, described Daily Goals as a “tool to help me be more effective as a nurse, to take better care of my patients while taking care of my coworkers as well.”
Peterson had been working on developing a non-blaming culture for the past several years. Staff have come to understand that when an error is made, or a mistake reaches the patient, most of the time, it's because the system has failed. Rather than an individual being fired (unless the incident is egregious), they are re-educated, and the system is fixed where possible or made transparent so that everyone is aware of the potential problem. CUSP modules on the science of safety have extended and deepened the shared understanding of how broken systems set staff up to fail, and affirmed a culture where staff are more likely to report system failures or defects.
Peterson's journey to standardization of CLABSI and ventilator-associated pneumonia (VAP) bundles and nurse empowerment is marked by evolutionary trends rather than dramatic shifts in practice or culture. When hospital policy and procedures were revised in 2010 to make using the central line insertion and maintenance bundles standard house-wide, it built upon several years of nurse PICC teams having used the bundles with good results. The bundles were already fairly standard, but with the policy, they were formally institutionalized.
Over decades, Morris had observed changes in attitudes toward nurses' speaking up from accepted to encouraged, to recommended, to expected. This evolution of nursing empowerment was fostered by CUSP. “With CUSP, nurses were able to formally identify an issue, and then formally and publicly fix that issue,” Hickman noted. “When she sees that a patient can be harmed, any nurse can formally fix that.”
In 2012, the Nursing department extended CUSP to create a wider culture of patient safety. Dressler said: “We had a team to eliminate CLABSI hospital-wide and be accountable for that, but CUSP has a broader nature because it can address any patient safety issue. We have CUSP initiatives underway in falls, pressure ulcers, medication safety, surgical site infection, CAUTI.” Staff wear many hats in this small hospital, and different individuals or units take the lead on different safety issues. Hickman summarized the key ingredient of developing a safety culture:
“To change a culture, the leadership must be 101 percent sold on it. It has to be inside of your insides. Your staff looks to see if you are committed. If they even smell flavor-of-the-month on you, they will not buy in, they will not follow you. We are doing it because it is the right thing to do. Failure is not an option. If you fail to change the culture, someone can die. It could even be your parent.”
In October 2012, Peterson is launching CUSP in all hospital departments and embarking on a CUSP training program for all hospital staff.
For more information about Peterson, please visit their website at www.petersonrmc.com.