Board Checklist

CUSP Toolkit

Who should use this tool? Senior leaders.

Checklist items Leader Responsible Date Initiated
1. Set an organization aim of annually assessing the safety and teamwork climate.    
2. Improve the safety and teamwork climate using valid measures.    
3. Set expectation for unit-level culture assessment.    
4. Require at least a 60 percent participation rate by doctors and nurses. (Hospital-level culture scores do not allow targeted improvement.)    
5. Review culture assessment data regularly (The Joint Commission requirement).    
6. Explore the relationship between culture and clinical outcomes.    
7. Hold the executive team accountable for an explicit action plan to improve safety and teamwork.    
8. Review the progress of safety and teamwork improvement monthly.    
9. Establish a policy that requires all current and new employees and board members to receive Science of Safety training.    
10. Set the expectation that a senior leader is an active member of each CUSP team.    
11. Ensure senior leaders meet with the CUSP team at least monthly.    
12. Hear at least one story of a patient being harmed from an infection at each board meeting. Discuss major patient safety events/errors that have occurred in the most recent timeframe to show that this is an important and ongoing concern.    
13. Work with the chief executive officer and chief medical officer to establish interdisciplinary patient rounds as an organizational standard practice.    
14. Review a summary report of staff patient safety assessments* no less than annually. (*“How is the next patient likely to be harmed on my unit? What might we do to prevent that harm?”)    
Page last reviewed December 2012
Page originally created December 2012
Internet Citation: Board Checklist. Content last reviewed December 2012. Agency for Healthcare Research and Quality, Rockville, MD.