Organizational Embrace of CUSP to Improve Patient Safety (Transcript)

March 20, 2012

Operator: Excuse me, everyone, we now have our speakers in conference. Please be aware that each of your lines is in a listen-only mode. At the conclusion of the presentation, we will open the floor for questions. At that time, instructions will be given as to the procedure to follow if you would like to ask a question. I would now like to turn the conference over to Louella Hung. Ma’am, you may begin.

Louella Hung: Hi, everyone. This is Louella with HRET. Thank you so much for joining our supplemental call this month. The topic is “Organizational Embrace of CUSP to Improve Patient Safety,” and today we’ll be hearing from two different organizations and their approaches to implementing CUSP in multiple areas of the hospital to reduce harm beyond CLABSI and beyond CAUTI to improve their overall culture of safety. We’ll also hear from them about the mechanics of how, at the hospital level, they’ve kind of stood up and supported their CUSP team. So I’m going to hand it over to Jeane Decosmo at the Maryland Hospital Association.

Jean Decosmo: Thanks, Louella. This is Jeane, and I welcome everyone on the call. I’m so pleased to introduce the speakers for the call today. Both teams presented at a CLABSI mid-course meeting and shared their strategies for organizational culture change.

I’ll start with introducing the Holy Cross team. Yancy Phillips is the Vice President of Quality and Care Management at Holy Cross. This hospital is in Silver Spring. He is responsible for a wide range of activities, including clinical informatics, case management, social work, patient safety, risk management, performance improvement, infection control and employee health, accreditation, and regulatory compliance. He oversees hospital initiatives in patient safety to reduce potentially preventable complications and readmissions as part of Maryland’s pay for quality program. Joining Dr. Phillips will be Sean Maxwell. He’s the lead angiography technician at Holy Cross.

And then turning to the Upper Chesapeake team, Jim Hursey joined Upper Chesapeake as a senior vice president and chief operating officer in December of 2011. He holds an undergraduate degree in economics and master’s in business administration. He has extensive experience in both the acute care and ambulatory arena. Prior to joining Upper Chesapeake Health, Jim served as the COO for the largest federally qualified health center in the mid-Atlantic region, advancing community health for the underserved populations. His acute care experience spans over 20 years and includes 16 years at Greater Baltimore Medical Center, where he served as the vice president over business development planning, strategy, decision support, and ambulatory development. He also held a similar role with St. Joseph’s Medical Center for nearly 4 years. Patient safety and quality have been a core foundation of his leadership philosophy.

Joining Jim is Judi Webster. She’s a RN with a BSN and has been in the patient safety role at Upper Chesapeake Hospital Health System since its inception in 2010 and has seen the impact of supported leadership in changing culture. Judi received her diploma in nursing from St. Joseph Hospital School of Nursing and her bachelor of science in nursing degree from Thompson University. She has numerous roles in health care ranging from bedside ICU nursing to director of a Medicare-certified home health agency, finally finding a niche in promoting patient safety in the community hospitals in her own backyard.

Thank you again to all of the presenters, and with that I’ll turn it over to Dr. Phillips.

Dr. Yancy Phillips: Thank you very much, Jeane, and I appreciate the opportunity to share our experiences here with the CUSP team. On the second page – and I’ll just flip through these individual pages and call out the changes – is the agenda today. A little bit about our hospital and how we got to deciding the CUSP teams were a critical lever for us in changing the culture of safety. I’ll describe the way we’ve adapted CUSP teams here locally, and then I’ll ask Sean Maxwell, who is our patient safety leader, frontline patient safety leader, on our interventional CUSP team, to talk to you a little bit about what they’ve done there, and then step back from the organizational level and talk about a couple of the real challenges that we have around burnouts and around clarifying messages for managers and staff overall.

The third page here is just a quick reprise of the Holy Cross Hospital. As a little bit of a background, we’re a fairly good-sized community hospital with a broad range of services with the sort of metrics that you see there. We’ve had the good fortune to be recognized as a top-quality performer in 2010 by the Joint Commission, but it’s in the area of patient safety, which is outlined on the next slide, where we’ve really not had the kind of traction in terms of the recognition of our staff for a lot of the things that have been done. The list of things that are shown here as Holy Cross patient safety initiatives are similar to what I’m sure very many or all of the folks on the line have done here, but we’ve really not — despite almost everything we do being about patient safety -- our staff’s appreciation of that or overall perception of safety has not been at the level that we think reflects the organizational interest in that.

The next slide shows the result of the AHRQ patient safety survey, which we did in December of 2010. I’m going to tie this into our journey, how we used this information to make some decisions. This was also the first time that we really put a very significant organization-wide effort into a valid survey. Before we had less than a third of the responses on an annual response, but I think our focus on getting good representative information from our population. We had about a 60 percent response across the hospital, and you can see by our scores there. And if you’ve got it in color, it indicates that most of our scores were below the 50th percentile nationally. Only the score on teamwork and frequency of events reported, so we kind of like working with ourselves and we have an open culture of reporting, but most of the other scores in there were not at the level that we thought they would be.

On the next slide, we show sort of the things that came together in the fall of 2010. One of which is that I had the opportunity to attend the Duke Patient Safety Course, with some representatives of our corporate office at Trinity Health, and the results of that 2010 December survey that I indicated to you. Along about that same time, our involvement with the CLABSI-CUSP initiative was a nice springboard for us to see that to sort of ignite us to spread CUSP across the hospital. And we made the decision that we were going to use CUSP teams across the hospital as the real lever to effect an actual change in our safety work and also the overall staff perception of patient safety. So we made the decision to invite Dr. Bryan Sexton, who is the head of the Duke Patient Safety Center, to Holy Cross Hospital to have a variety of programs that I’ll describe in just a moment.

On the next slide, even before we had Dr. Sexton here, we had decided on the structure, a classic CUSP team structure that has been promoted with the CLABSI teams with a focus on local processes and defects of care. And ahead of this meeting, we identified individuals, frontline staff members, as our patient safety leaders which were a critical position. We also clearly identified area managers, physician champions for areas, and a member of the senior management council at the hospital as part of the CUSP teams, and then identified other individuals to be involved. But the key roles of frontline patient safety leader, manager, physician champion, and executive partner were ones that we emphasized and selected ahead of time.

The next slide indicates how we went about selecting CUSP teams. We started, obviously, with the units that were participating in the CLABSI-CUSP collaborative. We also used the results of that patient safety survey in December to look at areas that had lower percent overall perception of safety and some other indicators, and we selected the units that you indicate here, not all directly nursing units but most of them frontline nursing areas. There were a couple of units that were paired up, just like we had paired up our ICU and CCU. A couple of our units had shared some similar staff or functions, and, for example, our L&D area was an area where we had wanted to focus on but our scores from our high-risk perinatal area were actually very good, but we wanted to team those areas into single CUSP teams.

And then we also had one area that we selected because we’d had a series of recent significant events. We had a couple of inappropriate, wrong medications administered during interventional radiology procedures, and that’s one of the reasons that I’ve asked Sean to be with us today. When these occurred and I sat down with the leadership in interventional radiology and asked, I said, “Was there a common thread here and do we have a personnel issue?” The answer was that the individual who was responsible or was involved in this was our lead technician, who is a star performer here. And so I invited Sean and his manager to my office, and while Sean might have thought there was going to be a personnel action, the reason I invited him to come was to ask him to take the role as patient safety leader for interventional radiology. In a couple of minutes, he’ll share with you some of the things that he’s leading in that area.

We also had a number of inpatient units that did not have CUSP teams, that we did not charter CUSP teams. There was a little bit of a public relations challenge because everybody — these are the units that were really doing very well and a number of their scores for employee engagement, satisfaction scores, et cetera – and they’re kind of wondering they didn’t get to have a CUSP team. But we’ve invited people from those groups to participate in the training, but we also wanted to focus our efforts on areas where we wanted to get some improvement.

The next page is a picture of Bryan Sexton. If any of you all have had the opportunity to see him, he’s a very engaging speaker. He’s done a lot of work, originally at Hopkins and now at Duke in patient safety, and we got as much out of him as we could over a 3-day period. We had a 3-day, between 4 and 6 hours a day of training, core patient safety training that Sean went to, that almost 100 other individuals participated in. We also sent out five 1-hour blocks of time for frontline staff to come to attend and get sort of a 1-hour mini seminar. We did the grand rounds for the medical staff on patient safety, and then we had a dinner with the medical executive committee to address some of the concerns about patient safety from the medical staff.

The next page is just an amalgam of the units that we have that have CUSP teams – 11 teams representing 14 units and about two-thirds of the frontline caregiving staff represented in that.

The next page is, I think, a positive result, some of that from that training. To get in synchronization with our overall organization’s pattern of surveys, we repeated the AHRQ survey just 6 months after we did the one in December. We were concerned about that in terms of survey fatigue. We had just completed an employee engagement survey just prior to that as well, but, again, we had very good turnout and had very substantial improvement in all of our scores, which I think indicated that we were headed in the right direction – not where we wanted to be, but headed in the right direction. Subsequently – actually just a month ago – we did a survey of about 20 percent of our employees and we had a further 6 percent increase in the overall perception of patient safety. So we’re pleased with the direction that we’re headed in, again, even though we’re not really there.

The next slide— I’m going to talk you through for a few minutes about our approach to the CUSP teams and their activities. This lays out what the expectations for the teams are: That they meet at least once or twice a month with separate executive rounds, that they work on local defects -- and we’ll talk a little bit more about defects -- and then we have set aside something we called protected time for the patient safety leaders, and then a group meeting where all of the CUSP teams get together. And I’ll give you some detail on that.

The next slide is just a reprise of the learning from defects that, I think, most folks are familiar with. The slide after that is titled Directed Defects Work, and this is specific issues that we’ve asked the individual teams to work on. We are working now and continue to work with hand hygiene and have asked each of the CUSP teams in their areas to work on that issue. Certainly, the CLABSI work in our critical care units, the recent catheter-associated urinary tract infections in the med-surg unit, and then we’ve actually developed, adopted the Learning From Defects with the root cause tool for specific defects for CLABSI, ventilator-associated pneumonias, and CAUTIs where whenever one of those is suspected, there’s an interview of staff members directly involved with the care of that patient before an infection may be detected.

The next slide is entitled Protected Time for Patient Safety Leaders. The hospital made, I think, a significant commitment in terms of setting aside budgets to allow up to 12 hours per month for the patient safety leaders to be out of regular staffing patterns and to have their time charged against patient safety. We know that everybody’s busy. Nobody’s busier than frontline caregiving staff, and we felt if we did not give some breathing space for those individuals, we’d not get the kind of traction we were looking for. That time is to be scheduled with managers and to have specific plans for how that time will be used, and there’s some examples given here. I also ask that, at the end of one of those blocks of time that are used, that the patient safety leaders send me a very brief summary of the kinds of things that they did, and for those that are particularly noteworthy, I forward them to the larger group just to give people examples of what’s going on. We have not yet gotten the full measure of effect out of that protected time. I think it’s been hard for people to schedule that, given the pace of clinical activities, but it’s an area that we think is going to be essential for getting traction.

The next slide mentions the CUSP all-teams meeting. So bimonthly, every other month, we meet. We have at least two separate times for that so that individuals on shift schedules, et cetera, can get to those, and we ask that the patient safety leaders, managers, and physicians try to attend at the same meeting. And we review information, data. We share experiences and barriers, and we talk about how people are using protected time.

So somebody who has been pretty good about using this protected time is Sean Maxwell, who is our lead angiographic tech here, and Sean is just going to talk to you briefly.

Sean Maxwell: What actually happened was that we had two instances where medication errors happened. And now, by policy, we use double verification or read-back and verification between two people and direct observation. And any high-alert meds we don’t keep on the table until they are needed. And the second thing that we worked on and had an issue with was outdated inventory. We actually implanted an expired item. Since then, we’ve labeled everything that was going to be outdated in a short period of time with red stickers and also do read-back with that as we do with medication.

And a couple of other things that we are working on is making sure that we are doing consent on an accurate, every day, every patient basis and getting everything tiptop, and I do that in my protected time. I take at least 10 of our monthly consents and make sure that everything is done, just do random checks.

Dr. Yancy Phillips: One of the things that Sean’s also done is work with some of the other areas for interventions in our cardio-cath lab and some of the other areas to do more direct observation for adherence to universal protocols in some of the core safe practices that are there. I think it’s had an impact not just on Sean and the technicians there but on the docs as well, who I think have much more bought into the need for this. Thanks, Sean.

The next slide is labeled as Sustaining CUSP. I think that is a challenge for us. I think the fact that we identified frontline staff without any management or supervisory experience and have really vested them with significant responsibilities has been a maturing process and a mentoring process. A couple of folks, I think, have found that that’s not something that they had been willing to do. We have not used this protected time, despite the fact that we budgeted it this past year and will budget again next year, and we continue to follow that and let people know when they are using and when they are not using their protected time. Engaging busy physicians and executives will probably always be a challenge, and we are interested in having areas that don’t have CUSP teams but that already do have strong, mature safety cultures. We want to make sure that we disseminate tools and learning opportunities to them. We’re just now looking at how we may go about chartering new CUSP teams in this area because, again, we started 11 off at the same time with a kickoff training.

And again, keeping organizational focus, I think that’s one of the challenges for us. On the next slide there is so much information. Health care is under such dynamic change, and I think sometimes it’s hard for the managers and hard for frontline staff to figure out what are the important areas, what are the unifying themes. So that’s been something that we’ve tried to work through. As we focus our organizational objectives, this is what we’re focused on, and we see communication and staff burnout as critical issues there.

Next page just has a couple of organizational initiatives that we are working on to improve both communication and working on resilience.

My second-to-last slide is titled Resilience. I think everybody in health care needs to be resilient, given what we all face in terms of the pace of work and the pace of change. And so we have just recently chartered a resilience resource team here whose job it is to help organize some of the existing resources that can promote both individual and group resilience and also to develop some new initiatives.

My final slide is much along the same, and that’s entitled Connecting the Dots. I think that’s a challenge for any hospital leadership team is how you bring all of these things together. We use a lot of terms. We have surveys and information. We have initiatives. But how do they all tie together? What reinforces what? I think our message here is that it is about patient centeredness, whether it’s in our CUSP teams ultimately, the role of our staff, the importance of resilience to the staff. It’s about the patient at the center and patient safety.

I appreciate your time. I think I’ve used my 20 minutes, and I’m going to turn the speaker over to Jim Hursey from Upper Chesapeake Medical Center.

Jim Hursey: Great, thanks, Yancy. Good afternoon, everyone. It’s a pleasure being with you today as we highlight some of the patient safety efforts ongoing here at Upper Chesapeake. Just a little bit of background – not to go through this -- I’m on page 26, slide 26. Upper Chesapeake includes two acute care hospitals. One is Upper Chesapeake Medical Center, and we’re located in Bel Air, Maryland. And the other is Harford Memorial Hospital, which is located in Havre de Grace, Maryland. They’re about 20 miles apart as the crow flies. Both are located in Harford County, which is in the northeast portion of the State. It’s about 20 to 40 miles northeast of Baltimore, roughly.

On page 27, just some details. We’re affiliated with the University of Maryland Medical System, which has been a partnership that’s really benefited both organizations in not only enhancing our services but also driving patient safety and quality results, really creating kind of a knowledge community for all the University of Maryland systems and affiliated hospitals in terms of how we enhance what we’re doing daily. We have about in total between the two acute care hospitals about 300 beds, about 25,000 admissions and observation patients a year, about 90,000 ED visits, et cetera. We’re a major employer in the market with about 3,000 team members and about 600 active medical staff.

On slide 28, senior leadership commitment. Senior leadership commitment, as you might guess in terms of supporting and building a culture of excellence, is paramount and essential. It’s readily apparent. I’d been with Upper Chesapeake for about 90 days. Most organizations are driving these types of initiatives, so we’re very fortunate to have a very active CEO in terms of kind of guiding and leading patient safety and quality. It’s readily apparent in our boardroom, to our units, to our OR and ED. Our patient safety and quality of care are core elements of our strategic plan, which really takes life in our operating plan, kind of where the rubber meets the road, and then it’s driven down to our departmental objectives, and then even to our team member goal setting and their evaluations at their level. The leadership team member incentives are all linked to those goals, patient safety and quality being included in that, and that really helps us drive accountability not only to the senior leadership team but also down to our team members.

Just like in any organization, if you don’t track it, you can’t measure your results. We have some pretty rigorous data collection and tracking processes, and every month we review that detail on our patient safety and quality results with our senior leadership team and, again, try to drive the results and the accountability at that level as well.

Kind of continuing on, we communicate this expectation kind of at the beginning of orientation of our team members. We share, probably in a very healthy and hard-hitting way, two videos, and they are a bit of testimonial driven. One of them, what’s called the Josie King video that we share with all our team members, was an incident that occurred at Johns Hopkins where an 18-month-old child unfortunately died as a result of medical errors, and the mother is the individual speaking in the video. It’s very hard hitting. It really kind of acclimates our team members from day one in terms of seeing real-life examples of how unfortunately we can cause harm. And then more importantly, the second video is what we call the science of safety video. It talks a lot about our willingness to admit our mistakes and then obviously learn from it. So that kind of really bakes in their minds kind of day one at Upper Chesapeake that it is about a nonpunitive environment, that is about safety, and then, more importantly, what do we learn from those events and obviously get better because of it.

And then finally we kind of bake some of that into our policies on a daily basis. We have what we call a Stop the Line policy, and that’s very similar to what you saw in the automobile industry, although we’ve obviously not working on cars here. This is really that any employee has the ability to stop the line in the interest of patient safety. We’ve seen it active in our units, our ORs, et cetera. It’s new for them and to some extent staff were a bit hesitant, but I think as people have stopped the line and have seen how supportive leadership has been all the way up the chain in terms of their willingness to do that, it has really bred a lot more trust in terms of their willingness to stop the line in the interest of patient safety, whether that’s with operating with a surgeon or what a team member is doing on the unit.

Moving on to slide 29, in terms of kind of where we are in terms of facilitating improvements at the senior leadership commitment level, it talks a lot about providing them the right resources. Yancy talked about protected time. We do the same in terms of supporting nonproductive time for participation in collaborative meetings, conference calls, and education, and data gathering for our team members. At the senior leadership level, obviously we need to model the behaviors in our division leaders in support of the culture of safety, and that really is supporting that speak-up approach and doing that in a nonpunitive, nonthreatening manner – again, 100 percent support for the team member that speaks up, whether they were right or wrong. It doesn’t really matter; it was more about stopping the line in order to assure that we’re doing the right thing. And then finally the last piece is a component that we do daily, which is what we call patient safety walkabouts. That’s a very engaging process where it give us a great opportunity to engage with our team members and staff, answer their questions, but, probably more importantly, get their input on what works and doesn’t work out in the real world in terms of the floors and the ED or ORs.

I guess my takeaway before I turn it over to Judi is that it’s really an opportunity to listen to our team members and get feedback from them, give them the opportunity to understand that we’re really working with them and for them to provide the right resources and really to enhance kind of the care we provide every day. And basically, it’s kind of acknowledging the communication between all of us that’s critical to our success and success in that area.

So with that said, I’ll move it on to slide 30, and I’m going to turn it over to Judi.

Judi Webster: Thanks. Back in 2010, our journey started. We added my current position, which is the PI Patient Safety Coordinator, and as a result of that we started doing what we call patient safety walkabouts. We took a look at our AHRQ survey, similar to Holy Cross, that we had done in December of 2009, plus we also do an internal team member survey. And we determined that getting our senior leaders and myself out and about to listen to what team members had to say was critical in shifting our culture to one of a culture of safety.

The questions that we focused on from the AHRQ survey were do team members feel free to speak up if they see something that may negatively affect patient care and the question are team members comfortable questioning the decisions or actions of those in authority. They really helped us stimulate discussion and set the tone for how our walkabouts were going to be conducted.

We chose the term walkabouts to kind of set these patient safety rounds apart. You know, we had EOC rounds, we have all kinds of rounds that are always going on. But we wanted to project a relaxed atmosphere where team members could speak up, and walkabout’s not quite so threatening as some of the other terms could be.

Of course, initially, no one wanted to speak up. This was brand new. They would talk about environment of care concerns or equipment that was broken, supply issues but not really getting into what we wanted to hear about, which were the process concerns. But as we would leave a unit to go to the next one, somebody would invariably pull me aside to tell me, you know, handoff communication is really not complete. We need to know what falls risk is when patients are going from unit to unit, so I would jot that down on my list and add it to some of the issues that arisen on the unit. And now when we make rounds, it very rarely happens. If I do have somebody pull me aside, most of the time it’s somebody who hasn’t regularly participated in walkabouts, so their comfort level is not quite there yet.

Moving on to slide 31, we, of course, participated in the CUSP-CLABSI collaborative project starting in November of 2010, and that’s when we started our monthly rounds in the ICUs. Prior to that in 2010, we had just done our walkabouts twice that year to kind of get our feet wet. Most of the feedback, again, that we got in our ICUs was very negative. There was still quite a bit of hesitancy about speaking up. Staff really didn’t think things were going to change much, and since we started that we’ve really seen a shift in the interactions in our walkabouts. Team members regularly give us proposed solutions. They think things through. They think about how things would work and make those recommendations. They offer feedback when things have been changed, both positive and negative. And in our process, we review any outstanding issues that haven’t been closed, and some of the issues that are big hitters, we also make sure that they have indeed been resolved.

Rounds now are much shorter. We do have an open forum, but sometimes in the ICUs there is really no new issues presented because we’re going there so regularly and we do a lot of follow up.

Slide 32 talks about flexibility and how necessary that is. We started out with doing an hour in each ICU in each facility every month. This, as has been alluded to already, is really a challenge, especially for senior leaders and other leaders. I can’t emphasize how important it is for the schedule keeper for the senior leaders to know how important these walkabouts and ICU CUSP rounds are, that they do need to be made a priority, and that it’s not a good thing to have to reschedule them multiple times. Senior leaders definitely want to do this, but it’s that schedule keeper that has to be on board as well.

We also discovered that 60 minutes was way too long. We initially started out with the concept of we would be in the unit and let people come and go and talk to us. Well, that didn’t work. We’d sit around chatting while we were waiting for team members to come in and out, and we didn’t want to be perceived as a nuisance so we narrowed down our time, narrowed down our tasks, and really tried to focus on what needed to be discussed at that meeting.

So our current process, moving to slide 33, is that we schedule 30-minute sessions; however, usually we’re there about 20 minutes in the ICUs. We’re doing quarterly rounds to the remainder of our nursing units and some of our departments, like the lab and pharmacy and imaging. We do invite all team members to participate when we’re on these rounds. So for folks like EVS, dietary, rehab, respiratory who really don’t congregate except for maybe reports at the beginning and end of the shift, we encourage them to participate when they’re on the unit where we are. We have all levels of leadership as well as myself participate. We let team members know what things we’re working on, what things we’re not.

This actually was a big help. We implemented a new computer system in September, and we consistently heard that the system was very slow. One of the physical therapists participated in our rounds and told us that this was a house-wide issue. This wasn’t just one particular unit complaining about it because she went all over the house, and she knew that it was just as slow on one unit as it was on the next. So upon hearing that, we got IT involved. They did a side-by-side analysis with stopwatches to time and see exactly what our team members were telling them. So currently, we have two pilots in place to try to solve this speed problem so that a permanent solution can be implemented.

With quarterly walkabouts, we try to visit every department, but as I stated, with the ancillary departments, they don’t come together as a group, so that’s a real challenge to pull them in. We’re doing better, but that’s still one of our biggest challenges is getting them pulled in.

Moving on to slide 34, accountability is the key. The grid has become one of the most important parts of walkabouts. I do take notes when we do our walkabouts. Don’t use names except for the leader that’s responsible for addressing the issue. We assign target dates, and then I complete the grid at the end of our walkabouts and that’s emailed to the manager of each unit, their director, and the vice president that’s responsible for that area. As issues are resolved, the leaders communicate back to me. I update the grid and redistribute it prior to the next round of walkabouts.

The important part here is the managers post the spreadsheets for the team members to review. If an issue can’t be resolved, I document that and indicate the reason why it can’t be resolved in a positive fashion, what the barriers are, what the issues are related to that. Team members started to be able to see that things were happening and started to see the walkabouts and patient safety rounds as a very valuable process because things were starting to get done. We do occasionally get issues and concerns about staffing and scheduling. They are referred immediately to the unit manager. I note that that issue was referred to the manager, and then we leave that at that level.

We also have unit-based nursing practice councils, which meet monthly, as well as our hospital nursing practice council, which meets monthly. And depending on what the issues are, they may be referred to the specific unit or to our larger nurse practice council. If it’s a multidepartment process or a system issue, it will be taken to our patient safety and quality council, sometimes our medication management committee, or any other committee that seems appropriate to get the issue resolved. We also do charter process action teams to address specific issues at times.

And here because we’re a two-hospital system, we do use a Skype-type system for conducting meetings so that input from both hospitals can be used because our facilities are different. Our Upper Chesapeake medical campus was opened in 2000, and Harford Memorial was opened in the ‘50s. So just facility-wise, we have some issues and differences in how systems and processes are, but we try to take those into account.

And one of the things that we discovered in going to multiple units and departments is -- using the same term that Yancy did -- we’re able to connect the dots better. When one unit raises an issue which appears to be a system issue, we can then ask all the rest of the units we’re going to the remainder of the day about that same issue. We’ve been able to identify some things between nursing and the lab. One of our good examples is our vancomycin levels. Previously, they were called to the nurse and then the nurse had to call it to the pharmacy, which interrupted the nurse and took a lot longer to get the drugs dosed. So now, we checked and the pharmacist is considered a primary caregiver since they are the one dosing the vancomycin, and results are called directly to the pharmacist now which helps increase the turnaround time for getting the vancomycin to the floor. The nurse receives results automatically on their status board in the computer, so they do receive the notification in a timely fashion as well. And this suggestion came from a nursing team member, and it’s worked out very well.

We also had an issue with – it sounds simple – but our imaging department expressed a concern about pillowcases on pillows when patients are coming from the ED, and so we were going to the ED next. When we arrived there, we found out that the ED had already addressed it, had already had discussions about increasing their par levels, and had changed their process to stop the pillowcases at the bedside. So we just communicated that right back to imaging, and that problem was able to be closed out the same day.

On slide 36, I have a sample of the walkabout grid. As you can see, it’s a very simple Excel spreadsheet. The detail of the issue is in the first column, something as simple as we need more hover masks on our unit. The primary topic and the subtopic are just a means to be able to sort easier if you want to look at trends, so for the hover mask, equipment would go in primary, hover masks in secondary. Update identified is obvious. The contact is that unit-level leader who’s going to work on the resolution, and the vice president is the contact person’s vice president. Notes and follow-up I track as we’re able to close items or activity related to items, and then target dates do change at times. And then when I do close out an issue, I physically move it to another spreadsheet for closed issues.

Moving on to slide 37, walkabout agendas. Short agendas are good. We start with a topic that’s a patient safety goal. Right now, we’re using “What barriers are you finding to hand hygiene?” as our opening question. We had new dispensers installed, so this really helped us identify some broken dispensers and some issues with dispensers. Hot topics – obviously anything that you’d like to communicate. This year in our Q1, we addressed organizational objectives. We share stories to learn from defects. We relate any case studies from recent sentinel events and talk about the lessons learned and how that may impact that area.

Under our open issues, we’re still working on this section to make it more concise for both parties. We tried using the question “How will the next patient be harmed?” And we found here that our team members, that kind of upset them a little bit. It was very personal to them, and it wasn’t a real good way to open up discussion for our team members. So we kind of shifted gears, and we started using the CUSP questions – “What are we doing well here?” “What should we stop or do less of?” -- those questions, and that’s been a lot more positive. “Who should be complimented today?” It really helps bring a focus on the positive things that are going on here, and it’s really helped everybody see that who should get kudos and who is really working hard, which is all of our team members.

We’ve had great success, as I said, with asking for solutions. We heard a lot about alarm fatigue and our charge nurse phones ringing constantly, so we had several suggestions on how our system could be changed to decrease those alarms. A process action team was formed. We did several pilot projects, and we made changes to the system, including having the vendor come in and look at our default settings and make them evidence-based, which really helped decrease the number of calls going to our charge nurse phone.

Another issue that we identified was our rapid responders didn’t have access to medications on all the units. They only had access to the medications on the units where they worked. So our pharmacy director controls that. It was a simple matter of communicating with her and having those names allowed to override to be able to get to the drugs that they needed in a rapid response.

Finally on slide 39, I know it’s very cliché, but it’s very true: Culture change is a marathon, not a sprint. It really takes patience and ongoing senior leadership and support and direction. Senior leaders need to have the pulse of their organization to be able to determine the timing for implementing various parts of CUSP, and they also need to be flexible. And that’s what’s really great here is that we have senior leaders that are willing to do that and work with all of our departments.

Our two hospitals have very different cultures, so sometimes our delivery methods and communications need to adapt to the different cultures. Our walkabouts sometimes happen in the nursing station. Some of our team members aren’t comfortable with that open forum, so we may move to their break room, wherever the team on that unit is most comfortable.

And another really important part is to communicate to the physicians how these changes will benefit them. We’re working on using SBAR, helping to streamline calls to physicians. I also report walkabout issues and resolutions regularly to our physician performance improvement committee, and they are very receptive to hear what’s going on. And my biggest message is be persistent and make sure that you focus on the most important thing and that’s the safety of all of our patients.

Thank you very much.

Louella Hung: Great, thank you. Before we open it up for questions, I do want to point out the last slide, you’ll see that there is a Survey Monkey link. As always, we welcome your feedback and let us know what you thought of this call.

So, Operator, can we open it up for questions?

Operator: Yes, Ma’am. At this time, if you would like to ask a question, please press star, one on your telephone keypad. Again, that’s star, one on your telephone keypad if you would like to ask a question. Our first question comes from Carolyn Canciello in Maryland.

Carolyn Canciello: Hi. Thanks for the great presentation. I have a question about the walkabouts, and I thought your feedback was really helpful. I’m curious about how many people participate on the walkabouts that aren’t on the units. So do you have, like, one or two senior members of the team and yourself from patient safety?

Judi Webster: Yes. We typically have—Jim joins us. We usually have the CNO. We have the vice president for performance improvement and myself, along with the director for whatever area we’re visiting ,and then the manager for that area as well.

Carolyn Canciello: Okay. And I heard you say you round monthly on the ICUs and quarterly on other patient care units?

Judi Webster: That’s correct.

Carolyn Canciello: Okay, great. How do you handle sort of some of the non-patient-related issues? Do they just kind of — I’m just kind of curious because I know having done these before in the past, sometimes they can become a distracter, and I wondered how you might handle that.

Judi Webster: Like I said, if it’s staffing issues, that kind of thing that are brought up right then and there, we just refer those to the managers since they’re right there, and we keep that at the unit level. If it’s a larger issue, our CNO may address it. And then for things that may be facilities or some other concerns, we add those to the list because ultimately they potentially could affect patient safety. We do notify the folks that need to fix things. A good example is the doors to our pediatric unit lock at 8 o’clock at night, and there were issues with rapid responders being able to get into the unit. The doors appeared to be broken, and it took actually a good 2 months to get that issue ironed out. It did affect safety because they were delayed in responding, but it really was an environment of care issue. So most of those kinds of things you can relate to patient safety as well.

Carolyn Canciello: Right, you’re right. Well, thank you very much.

Operator: Thank you. Again, if you would like to ask a question, please press star, one on your telephone keypad now. We are currently holding for questions, so again, if you would like to ask a question, please press star, one.

Deb Bohr: Hi, this is Deb Bohr from HRET, and I want to thank all four presenters. Just two outstanding case studies, if you will, and wonderful presentations. I think I could ask this question of both facilities: How long did the speak-up process take to really get teams comfortable with not just talking about the equipment, for example, and really not whispering and following after you, Judi. How long did that take for teams to get comfortable with that speaking up process?

Judi Webster: We’re still not 100 percent there. It’s taken a good 2 years, though, and it’s become easier in the ICU. I think the other important thing is the more often that you go, the more comfortable team members get with us being there and with speaking up. And I think that’s a bigger factor than anything else is the familiarity. Once they are familiar with all the players, they get a lot more comfortable.

Dr. Yancy Phillips: I would reinforce the fact that it does take a long time, and we have a similar Stop the Line program that we’d celebrate at our monthly patient safety council meeting. But I suspect part of it is just the persistence. You know, that this has to be seen as not the flavor of the month or of the year, that this is a long-term organizational commitment. And the better job we do of providing feedback, either through mass communication or through individual communication about our response to individual issues, the more, I think, real it becomes for staff.

Again, one of our focuses is on openness, open communication and on the domain from the safety question about non-punitive response to error. Our organization is going through a very formalized approach to just culture and decisionmaking around medical errors, and I think we want to keep those communication lanes open.

Chris Goeschel: Yes, this is Chris Goeschel from the national project team, and I would mirror Deb Bohr’s comments about the importance of the presentations that we heard today not only because they represent different versions of ground truth that perhaps was facilitated by some of the work that we’ve done together, but also because – and I think our last speaker has just pointed this out – these things take time. The technical work takes time. The culture work, the psychological safety that’s required to consistently speak up is a matter of investment in building trust on all sides of the conversation. So the notion of familiarity is important. The more times you meet with people, the more you get to know each other and the more you begin to think this is real and that it’s okay to speak up. The more widely the source of interventions are distributed and implemented throughout the organization, the easier it is for folks to say, “This isn’t the flavor of the month. This is something that’s permeating the organization.” And then when you begin to get the sorts of stories that we heard today and you get, I’m going to say, caregivers that are at the frontlines every day with an ability to talk about this, the more difficult it is to look at it and say, “Oh, this is a program that’s going to stop because it’s no longer a program.” It really is the way you do work.

So congratulations to both of you, and thank you so much – both teams – for sharing your different approaches to both spread and sustain this work. Such a great job.

Operator: Again as a reminder, if you would like to ask a question, please press star, one on your telephone keypad now. I’m showing no further questions in the queue.

Deb Bohr: Well, just a phenomenal job. This is Deb again. I worked with Chris and Louella and many others on our national project team that are on the call today, and we’re very grateful to Jeane and her team at the Maryland Hospital Association and we are very appreciative of the team members that presented today. Just a terrific job. Thanks so much.

Louella, do you have any final comments?

Louella Hung: No, but just a reminder that these slides and an MP3 recording of this call will be posted on our Web site, our project Web site, usually within 24 to 48 hours following this call. So if you have any other team members that you think might be a good thing for them to listen in on that, they can definitely do that. So I want to again thank our four presenters – Yancy Phillips, Sean Maxwell, Jim Hursey, and Judi Webster. We really appreciate hearing kind of the on-the-ground troops, like your stories and sharing that with the rest of the teams across the nation. So thank you very much, and this concludes our call. Thanks, everyone.

Page last reviewed April 2013
Page originally created April 2013
Internet Citation: Organizational Embrace of CUSP to Improve Patient Safety (Transcript). Content last reviewed April 2013. Agency for Healthcare Research and Quality, Rockville, MD.