Peterson Regional Medical Center Uses AHRQ's CUSP and Hospital Survey to Advance Patient Safety

Patient Safety
November 2014

Peterson Regional Medical Center, a 125-bed rural hospital in Kerrville, TX, is using AHRQ's Comprehensive Unit-based Safety Program (CUSP) to eliminate central-line associated bloodstream infection (CLABSI) among patients. The hospital also uses AHRQ's Hospital Survey on Patient Safety Culture to measure employee perceptions of patient safety.

AHRQ's CUSP features safety improvement strategies that combine communication, teamwork, and leadership to create and support a culture of patient safety that can prevent harm to patients. The program offers evidence-based safety practices, staff training tools, standards for consistently measuring infection rates, and other tools to improve teamwork among doctors, nurses, and other members of the patient's health care team.

Peterson Regional Medical Center implemented AHRQ's CUSP in 2010. It has been successful in reducing CLABSI, as evidenced by the fact that the hospital has had only two cases of CLABSI since 2011. It has also maintained a zero CLABSI rate since June 2013, reports Barbara Stehling, R.N., the center's director of quality services.

"We first implemented CUSP to improve patient safety and employee communication and teamwork within the intensive care unit," Ms. Stehling says, "and the processes soon flowed across the entire hospital. They were well accepted because they empowered our staff to be able to speak up when something did not appear to be right."    

In 2012, the hospital incorporated AHRQ's CUSP protocols for communication, teamwork, and leadership to address other patient safety issues such as falls prevention, medication safety, urinary tract infection, and pressure ulcers.  

According to Ms. Stehling, "The most important CUSP practice we introduced was the ‘safety huddle,' which is when health care team members periodically meet to discuss the patient's condition and any potential safety issues. Now the nurses and other members of the health care team really feel they have a sense of ownership when it comes to patient safety. Anyone can call a huddle at any point and speak up if they have a concern."   

The hospital also administers AHRQ's Hospital Survey on Patient Safety Culture about every 18 months to measure employee perceptions of patient safety.

This AHRQ survey is used by hundreds of hospitals in the United States to assess a facility's patient safety culture as viewed by its own employees. Hospitals voluntarily submit their survey results to a national database, which serves as a central resource so hospitals can compare their safety culture results with those of other hospitals. 

"The [AHRQ] survey identified continuing communications issues of the staff being reluctant to speak up when they had a safety concern," Ms. Stehling notes. "After we implemented the unit-based safety huddles, we've seen higher positive responses to several survey questions."

Results of the hospital's most recent AHRQ Hospital Survey on Patient Safety Culture showed significant improvement in communication openness, which increased from a 60 percent to a 66 percent favorable response rate. Positive responses for continuous improvement in organizational learning climbed to 80 percent. Another survey question on supervisor/manager expectations and actions promoting safety increased in favorability from 76 percent to 79 percent.

Having the support of the hospital leadership is a significant factor for successfully implementing a quality improvement initiative like AHRQ's CUSP, says Ms. Stehling.

She describes what she believes to be a necessary component for success in improving patient safety. "Our leadership expressed strong support for CUSP, and our staff followed right along. You need the leadership support because that helps everyone understand what the priorities are and what is most important, which is keeping the patient safe and providing compassionate, patient-centered care."

Impact Case Study Identifier: 
AHRQ Product(s): Comprehensive Unit-based Safety Program (CUSP), Hospital Survey on Patient Safety Culture
Topics(s): Patient Safety
Geographic Location: Texas
Implementer: Peterson Regional Medical Center
Date: 11/25/2014
Page last reviewed November 2014
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