University of Arkansas Medical Centers Improving Care with AHRQ's CUSP and Health Literacy Toolkit

The University of Arkansas for Medical Sciences (UAMS) has implemented several AHRQ tools—including the Comprehensive Unit-based Safety Program (CUSP) and the Health Literacy Universal Precautions Toolkit—with some eye-catching results. UAMS is the state's only comprehensive academic health center, with outreach programs operating in every county in Arkansas.

One year after implementing CUSP in a 30-bed step-down unit, for example, the unit saw a 92 percent decrease in catheter-associated urinary tract infection (CAUTI). "CUSP has been very helpful and effective," says Taleda Gore-Lowe, B.S.H.S., quality assurance coordinator in UAMS's quality management department. "Now they are looking at it [CUSP] for other areas, like [decreasing] falls."

The 450-bed UAMS got involved with CUSP in late 2012 when a five-member group (two quality assurance coordinators and three residents) went to a CUSP training. CUSP is an evidence-based structured strategic framework for safety improvement that integrates communication, teamwork, and leadership to create and support a culture of patient safety that can prevent harms to patients. With funding from AHRQ, a team led by Peter Pronovost, M.D., Ph.D., senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, developed CUSP to prevent healthcare-associated infections in hospital intensive care units.

The UAMS team decided to first address CAUTI and targeted the step-down unit, which had the highest CAUTI rate of any unit in the hospital. In implementing CUSP, "we found that we had several different Foley catheterization policies," says Ms. Gore-Lowe, who also serves as the team's leader. "Nursing [leaders] worked to streamline the catheterization policies and procedures."

The unit-based safety team partnered with senior executives and found a physician champion to help make CUSP a permanent approach on the unit. The team implemented safety rounds, trained staff in the science of safety, and let each shift know their CAUTI rates.

"What I'm hearing from nursing staff is that there is better communication," says Sandra Bennett, B.S.N., R.N., director of quality management. Early on, the team partnered with UAMS's patient safety officer to launch the CUSP toolkit's video, Understanding the Science of Safety, on a hospital-wide basis.

"I think the Science of Safety video gave everyone a foundational idea of where we were going, and that safety is everybody's responsibility," adds Shannon Finley, M.S.N., R.N., quality assurance coordinator in UAMS's quality management department.

The video helped to ignite the step-down unit's effort at targeting CAUTI. As the team began the CUSP implementation, the unit experienced 12 cases of CAUTI in the first quarter of 2013. A year later, the unit had only one case of CAUTI. "Several times during the year, we had zero [CAUTI cases] for the month," Ms. Gore-Lowe reports.

Using another AHRQ tool, the Health Literacy Universal Precautions Toolkit, the UAMS Regional Family Medical Centers implemented a health literacy training program for multidisciplinary clinical staff, faculty, and family medicine residents. Eight centers launched the program across the state from January 2012 through April 2013.  

The AHRQ health literacy toolkit provides step-by-step guidance and tools for making improvements in health literacy practices and includes suggestions for tracking progress. UAMS used the toolkit to help its centers make changes in clinical practice in all four areas addressed in the toolkit: spoken communication; written communication; self-management and empowerment; and supportive systems. The toolkit helps medical practices take a systematic approach to reducing the complexity of health care to ensure that patients can successfully navigate the health care system.

A total of 322 multidisciplinary clinical staff, faculty, and family medicine residents were trained in the literacy program. Participants were assessed for perceptions of health literacy practices prior to training using the toolkit's Health Literacy Assessment. Three one-hour in-person and remote toolkit training sessions were conducted. Participants assessed the clinics again six months later. Results indicated improvements in perceptions in all four areas addressed in the toolkit, meaning clinical staff members were doing better with using health literacy practices. The area of greatest improvement occurred in practices related to patients' self-management of diseases, which improved by 22.7 percent. Moreover, strategies, benefits, successes, and problems with implementing the toolkit were identified.

While the staff perceived improvement related to health literacy and the effectiveness of the tools in several areas, they were concerned as to whether the changes could be sustained over time. Staff members thought that the toolkit was rolled out in a top-down approach. In order to make the toolkit and health literacy efforts more lasting, UAMS is revamping the way the toolkit is being implemented (more organic and bottom-up) to realize lasting change, says Kristie Hadden, Ph.D., UAMS assistant professor and director of the UAMS Center for Health Literacy.

"While the training program demonstrated significant improvement in staff perceptions of health literacy practices, reluctance to continue implementation was noted because it was viewed as 'one more thing to do,' and 'we don't have time to do this on top of everything else,'" notes Dr. Hadden.

Clinical and program leaders held discussions about how to proceed. They decided that the clinic outreach directors, who are part of the clinic team and are responsible for health education and connecting patients with resources, would be best suited to assume health literacy team leader positions. It was also decided that implementation should take a much slower pace to accommodate staff members' busy schedules and to relieve some of the burden associated with other organizational changes, including new electronic medical records and patient-centered medical home certification efforts. These outreach directors took over the toolkit implementation in August 2013 and re-introduced the toolkit through early 2014.