Two More “Es” and How To Spread (Transcript)

December 13, 2011

Operator: Excuse me, everyone, and thank you for holding. Please be aware that each of your lines in a listen-only mode. At the conclusion of today’s 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 call over to Dr. Jill Marsteller. Ma’am, you may begin.

Jill Marsteller: Thank you. Hello, everyone. As our operator said, I’m Jill Marsteller, and some of you may not know me. I have been the coach for several of our states in the National on the CUSP Stop BSI program for Wisconsin and Indiana and District of Columbia, and I’m still the coach there, and Massachusetts, as well. In addition to that, I work at the Johns Hopkins School of Public Health, and I work in a health and policy in management department, teaching courses generally on organizational theory and how that’s related to patient safety. So, I’m really pleased to be here today to talk to you about two more E’s and How to Spread. And if I may say so, I think I’m the one that actually coined the phrase “two more E’s,” and I will tell you what I mean by that in just a moment.

Going to slide 2, I want to just remind you that we’re looking for your feedback on this call, so when you have a chance, please go to the Survey Monkey link there and offer your feedback. Our learning objectives for this call are to think ahead about ways to make your investment of time and improvements in BSI rates last forever. So, you’re in the thick of it now. You’re reducing your blood stream infection rates or you’ve already had some great success, and you are getting it so low you can barely even see your infection rate anymore. And you think now that that will just automatically always be the case, and yet, we need to remember that, in fact, it will not always be the case unless we plan a way to make it always be the case. And that’s one of our subjects today. In addition, you will also, by the end of the call, be able to describe ways to make sure that all the patients in your institution have access to the same level of safety in your care. And so, by that, we sort of hint at what we’re actually talking about here. Sustainability is our first bullet, and expanding the project to other areas and possibly other topics is the second subject of our talk today.

So on slide 3, you can see there, the good old four “E’s” implementation framework. If you guys have been paying attention for the last 11 or 12 calls now, probably this implementation framework has popped up more than once. This is how we at the national level guide ourselves as we implement our program and, in addition, we suggest that you use it at the local level to guide your implementation as well. And so you remember that it starts with engaging. So at the level of the frontline staff, the team leaders, and the senior executives, you want to make sure that all of those people are engaged. You ask yourself, “How does effort make the world a better place?” and you communicate that information. What is it that we’re trying to do here? And we’re trying to touch that chord with each of those people. The chord that really sings within them, suggesting, “I care about this.” That’s what we’re trying to stimulate is the caring about this particular topic, about improving our blood stream infection rates, and our patient safety more generally. Then, we educate. So this is a step where we say, “Okay, we have to tell them what they need to do.” We have to convert the evidence into actual behaviors, tell people what steps they need to take, and then make sure that they are aware of what these steps are and how much they agree with it. And then dealing with whether they agree or not can be also part engagement, part education. You have to deal with that in a way that you can’t necessarily be taught to do, but you have to be receptive to the people’s comments and respond to them. The execution step, of course, is how do they actually do it. And as the person trying to execute on your unit, you want to listen to the resistors, you want to standardize care and create independent checks, and always learn from mistakes as they unfold. And then finally, you want to evaluate. So how do we know that we made a difference? You want to ask that question so that you can tell others how you know you made a difference, and I’ll explain in a minute how that’s really important for both the mental health of the people within your own unit to share that information. But also it helps your patients the more you share your successes in various places and get others interested in doing the same thing. So the two more Es that I like to talk about, I call “endure” and “expand.” And so endure means make your excellent success endure. How do you go about making the changes that you’ve made endure over time? More recently, people have been referring to this as embedding the intervention very squarely into your unit so that it’s routine. It’s practice as usual, right? It’s no longer this new thing that we’re doing, this different thing that takes me more time, but rather it is common practice. And then how do you know that it will last? What can you do to make sure that the changes that you’re seeing in practice now are, in fact, still being used 3 years from now? And then, for expanding, we want you to think about who else within my institution needs to know this? Who else places lines? Who else maintains lines? Where can we take this set of CLABSI prevention practices so that all of our patients are uniformly safe, okay? And what else do we want to work on using our CUSP program to try to improve the general safety of our care? So that’s what we mean by endure and expand. And you want to ask those questions again with reference to your frontline staff, your team leaders, and your senior executives. So for example, your senior executives, when you say, “How do I make this program endure?” the question with respect to senior executives is they want to see what effect you had. Were you successful? You have to give them that information. You have to try to be able to tell them what your estimates are in terms of money saved. You need to be able to argue to them lives saved so that they then maintain the commitment at the top level, which allows the unit to maintain its commitment over the long haul.

So moving to slide 6, I’m arguing that you need to plan to make this program endure. And so this is your plan for sustainability. This is how we will sustain our CLABSI reduction and how we will continue our CUSP program over the long term. So why would you worry about the distant future? I mean, after all, we’re busy enough just trying to reduce CLABSI right now. We have a couple of defects that we’re working on. It’s really hard because everybody is busy, now you want me to plan for sustainability, too? And I’ll say, “Yes, I do,” because what is going to happen to you over time, what you can anticipate happening is, you’ll have turnover, obviously, of your staff. You’ll get some new staff in there. There will be new projects. There will be distractions. Someone from management level will say, “We really need to concentrate on X. You’ve really got to fix this problem over here, this problem Y.” And so there are going to be new things that come along. The distractions, well, maybe they’re putting in a new EMR. That’s enough to drive anyone to distraction. And so, you’re facing new projects and distractions, and they are going to all pull you away from maintaining your practices with respect to BSI prevention, and with learning from defects, and various other steps of CUSP. There also is the danger of complacency. So at some point, people feel like, “Wow, we’ve done a really great job with this, and it should run itself from here.” And there’s sort of the notion that, “We haven’t had an infection in so long, we must be doing it all right, and the chances of our having an infection in the future are very small.” And so people then begin to kind of get lax. They begin to relax a little bit. And then compounding this, we also have emergencies and complex cases where someone will say, “This is an exception. We can’t do it the way we normally do it. I’m going to have to place a femoral line. There’s no time.” And that kind of thing happens, but the more often it happens, then the less routine is your practice, the less you can say that “We always place lines correctly,” right? So that’s something that over time can really wear away the enduring quality of your program.

On the next slide, slide 7, I’m suggesting that there are many things that you can do now to support your long-term viability of the reduction that you have already enjoyed of your CLABSI rate. And these include, for example, writing your line insertion and line maintenance practices into policy, to make sure your policy is fully up to date with all the practices, and of course, be sure that it’s up to date with all the new changes from CDC. But make sure that it’s in policy so that if anybody goes to look for the policy, it reflects current practice, not practice 3 years ago, the last time you looked at the policy. In addition, make sure it’s included in your training for all of your new members. All of the people who are new to your unit need to be trained on this. And maybe that’s kind of an obvious thing. I think oftentimes people expect with programs that somehow the new people will kind of absorb the way that we do things around here and that they don’t need to be explicitly trained. I think that you want to avoid that mentality and make sure that it’s part of your training. And also make sure that there are regular checks on people’s facility with the line maintenance protocol, with the line insertion protocol, just to make sure that it’s routine practice, but that everybody is also doing it correctly and fully in compliance, and that they didn’t pick up a bad habit from somebody else who wasn’t fully trained, for example. So you can audit and monitor the use of the line maintenance protocol, the line insertion protocols, just to make sure that it is, in fact, being done routinely and that there are not these weird little things happening, where “Gosh, it seems like there is a new trend of people not wearing their hats.” You never know what’s going to be the source of some variation from the way you’re doing it now, and we don’t know what the implications of every variation are, but that’s how we work our way towards an unexpected infection after a long time where we’ve had really great success.

So, also, pay some attention to setting up a reliable supply chain. So what this means is you think about your line cart or your line kit you have set up. Make sure that you have a way of perhaps a borrowing protocol or some other kind of alert system to be sure that you always have the supplies that you need, that there is never a case where somebody is trying to do the right thing, they go to the line cart, they’re ready to use the appropriate supplies, and something’s missing. And so you end of with a violation of protocol not because they didn’t try to do the right thing but because something was missing, right? So make sure that somebody is assigned to making sure that the line cart is always well stocked or that a kit is always available. And the other useful thing about this is that you will occasionally get an insight into something that’s not happening the way you think it’s happening. One of our teams in a previous project reported to me that they just happened to notice one day that in the supply room, the drawer that held the full drapes, the full-length drapes, was overflowing with all of these full-length drapes. They began to suspect that people were going into the supply room and pulling out a three-quarter drape and stuffing the full-length drape into the other drawer and using the three-quarter drape. So there they had this situation where there was this little change in the plan going on, and the only way they figured it out was it wasn’t immediately obvious to them. It wasn’t showing up on the checklist, but they found it by looking in the supply room. So, there are other benefits, also, to that reliable supply chain and monitoring it.

Make sure going forward that you’re having at least quarterly reviews of your rates by an executive partner, talking quarterly, at the very least, about your CUSP program, the defects that you’re working on in CUSP, and about your culture of safety results, and what you can do to try to improve those. So make sure that that contact doesn’t stop, and try to be sure that you’re building in an actual review of the data with them so that they can be fully aware. Everything remains transparent, and they can keep supporting you because they have the data to go to their bosses with. Further, if you can set up a learning network among your peers that endures past the length of this project, past the time when you’re not receiving. You’re in your own sustainability mode within your State, and you want to make sure that you‘re still talking to the other teams that you worked with to reduce blood stream infections. And you’re using the CUSP program because that’s the way that you get new ideas. That’s the way that you hear about somebody’s wonderful successes in a certain area, and that learning network that you formed together with your peers will be an invaluable source of new ideas, solutions, and all sorts of satisfaction, for that matter, of associating with people who also care about the same things that you care about.

And just as you’re going to maintain your contacts closely with your executive partner, make sure that you’re also having regular meetings going forward into perpetuity with your infection preventionist and that that person stays very engaged on your unit.

On slide 8, these are just a couple of nuggets that came out of the Michigan project, the Keystone ICU project, where after 4 years, they went back to look and see whether the reductions in CLABSIs had been maintained. And sure enough, they found that, in fact, the reductions were maintained. And some of the practices that they felt had aided that long-term sustainability included, for example, offering continued feedback of infection data. So they kept hearing what their infections rates were. They kept the banner up that said whether or not they had had an infection over the last “X” period of time. The data never stops streaming, even though they may have been working on it on their own, and so that’s really important because if people don’t know what’s going on in terms of your infection rate, there is no way for them to fix it. There’s no way for them to be concerned or feel that they need to act.

In addition, they felt that the improvements in safety culture that they saw over the length of the Keystone ICU project also enabled the CLABSI reduction to be maintained over long term. And so, just think about that for a second. When you know that everyone on your unit cares about safety, that people feel free to speak up, that it’s a priority of management on your unit level, and so on, then you can see how that would all be very supportive of keeping your infection rates low and working on other safety problems. And so, if you can focus on safety culture using your HSOPS results and try and improve some of those numbers that maybe you don’t think are where they could be, then that’s going to also help you maintain a more safe environment within your unit over the long term. They also felt that there was never any failure in the belief that blood stream infections were preventable. So they never found anybody suggesting that maybe they’re not. In fact, everyone kept suggesting, “We do believe every infection, virtually every infection, is preventable, and so we are going to keep preventing them.” Further, they found that the involvement of the senior leaders, who continually reviewed that data and continued to provide the teams with the resources that they needed, was a critical piece to being able to sustain the low infection rates that they were able to reach during the implementation part of the project. And the fact that they had this shared goal across all of the ICUs that were participating in the State versus this kind of competitive thing across different hospitals within a State, where “I’m not really going to tell you how I feel about that suggestion that you just made because I don’t think it’s a very good one, but in my hospital, we have to worry about our reputation, and vis a vis you, I’m not going to tell you that I’ve got this great idea that will really fix your problem, because we’re competitors, right?” That’s not what we’re looking for in this project. We want everybody to be supportive of one another, and the fact that they were in Michigan, they felt, was an important source of sustainability there. They kept their rate low after 4 years.

So let’s shift gears here a little bit, and on slide 9, we’re going to start talking about why you might want to think about expanding the intervention into other units. So you may have started just with your ICU or you might have started with one or two ICUs and now you’re sort of considering this idea of, “You know, lines are placed in lots of different parts of the hospital, and, you know, we do have some patients whose lines are maintained in different parts of the hospital than the ones that we’ve focused on so far. We’ve really got to extend this extra safety that we have going on in our ICUs throughout the institution.” There are many reasons for you to think about expanding to other units that are actually beneficial to the starting unit, as well. It’s obviously beneficial to the other units, but it’s also beneficial to you. Part of the reason is because it requires you to really think about the way you’ve done your program yourself because you’re going to go tell somebody else how you did it. You are going to tell someone else what you think they should do, right? How they might adapt what you’ve done to their area. You’re going to be working with another unit, perhaps. This requires you to really understand yourself, what exactly you’ve done, where your strengths are, and then analyze some of your own weaknesses. And so, it can really make your own program better when you try to go teach someone else how to do what you did. In addition to that, when you look at other units, you might see that, “Oh, wow. I didn’t realize they were like that. They’re really set up differently than we are.” Or “They have a different culture than we do.” And this may really offer you some new ideas and new methods, and they are going to be coming up with their own ideas. And you can tap into that wealth of knowledge, and so it can really be helpful to you, the unit that is spreading, as well as to the unit that receives the spread. Now, a slightly different idea is the notion of spreading to new projects, so you worked hard on CLABSI, as a clinical focus. What other clinical foci might be important for you to think about? Obviously, HRET is working with CAUTI. There are other people who are working on the ventilator-acquired pneumonia. And so these are all areas where you might start thinking, “Where do we need to expand our clinical focuses to enter other areas?” Why would you do that? Well, remember that quality can always improve, so you might be really good in a lot of ways, but there may be areas where you know you’re not doing as well as you could. You also have just built this wonderful capacity over the time that you’ve been working to reduce blood stream infections and learning about the CUSP program and using the CUSP program. You have this new capacity to change. You have much more ability to control and move in the direction you want the things that you don’t like, and so, you want to use that new capacity to make your care better overall. In addition, it really maintains your engagement of staff and their interest, the attention of management, if you can show that not only do you have really low blood stream infections, but you’re also working to reduce your VAP rate and various other clinical focuses that you know they care about. It really helps people feel engaged and, of course, we know that the CUSP program is supportive of various different clinical focuses, so you maintain your CUSP program as you maybe expand into some of these new clinical focused areas. It also allows you to kind of pick what you want the next initiative to be, if you then go to your senior leader and say, “We really want to start working on this project.” That may protect you somewhat from having it come top-down where you don’t get to pick where your next project will be. And, in general, when you’re working on quality improvement, you’re working on improving your patient safety, it’s just a much more rewarding environment. It’s a stimulating job for people to go to because they know that it’s getting better every day. IHI, the Institute for Health Care Improvement, offered a white paper about spreading an intervention from one area to other areas, and so we’ve provided a couple of summary points from that for you, and there’s the citation at the bottom. The notion here is primarily that you have to realize if you’re going to spread it, it may occasionally happen where a unit comes to you and says, “We’re really impressed with what you’ve done. Can you show us how to do what you’ve done? We also want to do it where we are.” But a lot of times, it’s going to come from the top, where somebody at the top says, “Well, this ICU has done a great job in reducing infections. ICU, we want you to now go over to the floor, and we want you to spread it to the floor.” Okay, so it could happen either way, but you need the support of management, generally, in order to be able to try to spread it because they will need additional resources, and they’ll need support the same way that you have that support for the additional unit to try this intervention. And the other advice that they give us here is to just really plan it out, not just think that, “Oh, we’ll let them come watch us two or three times and then they will be able to replicate what we’ve done, right?” And in fact, you want to do it more methodically. You want to define what your specific goals are for spreading it. You want to say, “This is our target. We are hoping that these specific improvements will be made.” And define the timeframe of the spread effort, as well. Try to make it a little bit more structured but keeping in mind the whole time that this is a dialogue between the spreader, meaning you -- the unit that’s got great success so far -- and the spreadee, meaning the unit that’s receiving your spread attempt.

So we’ve talked a lot about what you can do to sustain your CLABSI rates and your CUSP program, and we’ve talked about ways that you might consider expanding the intervention. And just to close, I want to take you to the last slide, slide 12, which talks about what your actions items should be with respect to this idea of making sure your program endures over the long term and also expanding. So those last two “Es” for us, in turning our four “Es” into six “Es.”So your action items, as we look to the future, are to start planning now for how you’re going to sustain the intervention for years to come. One of the issues that happens commonly is there is somebody who is really important to the current project that you have going, and then they get a great offer to move to Florida, and they do. And so, suddenly, your CUSP team doesn’t know what to do. “We just lost our leader,” or “We just lost a really important person within our team. What are we going to do? Who is going to take over?” So you have to make sure that you’ve got a line of succession. You know who’s up next. Who’s the number two? Who is going to take over things in case you have this kind of turnover? You need to think about that kind of planning before the event occurs, and so that’s what your first action item is.

Your second action item is to think about working with your executive partner and your unit heads to try to figure out where else should this intervention go? Where do we need to protect our patients? What is a logical rollout strategy? What, again, are our timeframe and our goals, and how can we do this so there’s minimal disruption of day-to-day activities, and yet we’re protecting all of our patients equally?

And then, finally, spend some time engaging your staff, trying to find out what kind of next activity, what kind of next clinical focus they might be interested in. This may come out of one of your learning from a defect exercises. You may find a lot of people being worried about a specific clinical area, and so the more you can get them to contribute to the selection of the thing that they want to work on, the better ownership, you will find, people have over that particular topic. But keep in mind you’re going to do that at the time as you keep doing everything right with respect to your CLABSI prevention and practices because we don’t want it to be a distraction from that effort. We don’t want to see an unintended effect of your CLABSI rates bouncing because you started focusing on another area.

Okay, so our final slide there just offers you some references. And, with that, I would like to open the lines to see if anybody has any questions or comments, notions that you think are particularly useful about how to sustain over the long term.

Operator: At this time, we will open the floor for questions. If you would like to ask a question, please press the star key, followed by the one key on your touchtone phone now. Questions will be taken in the order they are received. If at any time you would like to remove yourself from the questioning queue, please press star, two. And once again, to ask a question, that’s star, one.

Jill Marsteller: As we wait for questions, I just am brought to mind some of the data I have from a previous project where they were trying to improve chronic illness management. And this was in some primary care practices, as well as some hospitals, with a large national project that looked at several collaboratives. And one of the things we did as part of that project was call them 2 years later and ask them, “What portions of this intervention are you still using?” And while most of them were still maintaining the gains that they had reached, a much smaller proportion of them were actually still using the change process, still looking for new things to work on, and six of the sites had actually just dropped everything. And so you never think that you’re going to be one of those sites that a couple of years from now isn’t doing it anymore, and yet we know that that happens. So you want to make sure that it doesn’t happen to you by doing a little planning up front. Do we have any questions?

Operator: Our first question comes from Theresa Hickman with Peterson Regional Medical.

Jill Marsteller: Hey, Theresa.

Theresa Hickman: Hey, Jill, how are you?

Jill Marsteller: I’m good.

Theresa Hickman: One of the things that we’ve done down here at Peterson that I believe has made a really big difference is that I have incorporated what we’re doing, and I teach it in new nursing orientation. And, I mean, just the whole process, so that they’re aware of what we’re doing and know what’s going on when they come in. In addition, we teach every single month, we teach IV classes, that is a 4-hour class that we teach how to care for central lines, how to do the bundles, and so we keep it in front of the nurses all the time. And then the other thing that we do is we have spread out. With Adventis, I did everything, but here at Peterson, what we’ve done here is spread out all the different activities among different people, so not one person is running it all. We’re all running a little piece, which helps if one of us drops out for one reason or another, another one can pick and move on. That has really helped us as well as spread the workload out a little bit.

Jill Marsteller: I think that’s a wonderful observation. All of these are terrific things that you’re doing. But in particular, I really like this last one that you talked about. And I do remember in your earlier effort, you were pretty much the person doing it all, and we may have many people on the line who are in the same position where they are pretty much making this thing happen. And sometimes they’re the infection preventionist. They might not even be somebody who’s really always on the unit. And that’s hard. It makes it, I think, unsustainable because that one person could leave. That one person could get burned out. It’s very, very possible to get burned out. Or there could be any number of changes in circumstances. The person may be called to do something else or pay more attention to something else, and so I really like what you’ve suggested of having some of the different activities spread out over different people. It also means that you have some good buy-in in a number of individuals, and it’s not just one person always pushing it. That sometimes can help with other people’s receptiveness to the idea. It’s not just one person who keeps talking about this. It’s actually a whole bunch of people who keep talking about this. And that really sets a tone for the whole unit and for everyone that this is something that we all care about.

Theresa Hickman: Right, and it’s been very exciting in new nursing orientation, when I explain all the different things that we’re doing with the CAUTI and the new VAP stuff that is going to come out, how these new employees automatically want to be involved. They want to take a part, and that’s very encouraging as well as exciting, especially since we get a large number of new grads here. The buy-in is in the beginning. We don’t have to get them to buy-in later. We catch them right at the beginning.

Jill Marsteller: Right, right, when they’re still fresh, and they’re still full of idealism and excited about the new job. That’s terrific, and you’re building nurses who are going to know what to do wherever they go. This is a suite of well-trained individuals who are going to be improving quality nationally as they go from place to place.

Theresa Hickman: Right. And as a result -- can I brag a little bit?

Jill Marsteller: Well, sure.

Theresa Hickman: As of this month, we have been 23 months without a CLABSI in our entire hospital.

Jill Marsteller: Wow, that is terrific. That’s really great. I’m glad to hear it. So did you start out with one unit and then spread it to other units, or what was your approach?

Theresa Hickman: Our approach was that we started out basically the whole hospital. We have a PICC team. Ninety percent of all our central lines are PICCs, and we started out the PICC team in the ICU, and then we just rolled it out to the whole hospital. A lot of our work is done by the PICC team, especially on the floor. They do a lot of one-on-one teaching with the nurses on the floor, and regarding how the site is supposed to look, how to keep it running, and dressing changes, and it so it makes a really big difference that we have this team on the floor every day, and they do inspections of all central lines on the floor every day.

Jill Marsteller: Wow. Okay, well, that’s great. That sounds really good, so some terrific advice from Theresa, and congratulations. That’s really great. So are there additional questions?

Operator: Yes, Ma’am. Our next question comes from Chari Busby with East Alabama Medical.

Jill Marsteller: Hi, Chari.

Chari Busby: Hi. Just a question about the follow-up survey: When is that usually done in the project? Will it be in the spring or summer months, our safety survey? This is for the State of Alabama. Do you know offhand?

Jill Marsteller: Well, let me call on one of my HRET friends who are on the line, as well, for Alabama. And may I ask, are you talking about the patient safety culture survey?

Chari Busby: Yes. We’re trying to look to see how we just shore up on that. I know we had a timeline. We started our project, I think, in July or August of 2010, and so we’re coming to an end soon in Alabama in the next probably 6 or 8 months.

Jill Marsteller: Okay. And did you do one in 2011 so far or not so far?

Chari Busby: No, we did not. We did that first survey probably in November of 2010.

Jill Marsteller: Okay. So it really is time because we like to see them done on an annual basis. Let me see if Deb or someone from HRET can comment on that.

Deborah Bohr: Hi, Jill, and hi to Alabama. I do not have a specific answer for you. This is Deb Bohr from HRET. I don’t think we have anybody from Michigan Keystone on the line, so what we will do is in a Friday update, we will get to all of the State leads, and we’ll make sure that Carrie Rhodes in Alabama knows when the next schedule is.

Chari Busby: Right, and that was what I was about to say. I could email her also.

Deborah Bohr: But I think that it’s probably beholden on us to get the date to Carrie, so thank you for asking that question, and Jill, of course, is always spot on. It’s about time. We’ll get through the holidays and then let you know in early January so that we have that administration of the HSOPS in, say, January/February timeframe. So we’ll get back to you with more clarity on that, and thanks for asking the question.

Chari Busby: Right, thank you.

Jill Marsteller: Good, good. And so that will also help everybody with your planning when you get that information about when you should be thinking about doing yours again. Remember on our culture surveys, we want to try to get as high a response rate as we can because it’s essentially people’s perceptions of the culture. You want to be sure that you’re getting an accurate assess of that perception. If, for example, you only got 30 percent of your people to respond, well then you would say to yourself, “Okay, is this 30 percent representative of all of my people, or are they ones that have really rosy views, and they’re happy to answer surveys, and they always do everything you ask them to?” Well, if that’s the case, then you may be missing some really important information that there are another 70 percent, in this case, who maybe are not as full of excitement about filling out surveys and are possibly not as rosy in terms of the way they look at things. Just to reiterate, it’s really important to plan ahead and try to get as good a response rate as you can for those so that you end up having good data to work with as you work to improve your culture. Do we have any further questions?

Operator: Once again, if you would like to ask a question, that’s star, one on your touchtone phone now. Our next question comes from Carrie Rhodes with the Alabama Hospital Association.

Jill Marsteller: Hi, Carrie.

Carrie Rhodes: Hi. I was on the line, and I do have an email set to go out probably the last week in December or the first week in January. Alabama will be doing the HSOPS in February, and there are two training sessions in January, so I am on top of that, and they’ll be getting some information about it soon.

Jill Marsteller: All right, terrific. That’s it, thanks.

Female Voice: That’s good news.

Jill Marsteller: Okay, so did anybody else have a thought or want to share a story about sustaining over the long term or your success in expanding your project?

Operator: At this time, I am showing that there are no further questions.

Jill Marsteller: Okay, well I want to give you just a few more minutes to stop and think, “Is there something that I’m particularly proud of?” Or, “Is there a way that I have tried to build sustainability into my site’s CLABSI and CUSP efforts?” And while you think about that, I just want to comment that sustaining CUSP is really what the program is actually about. You may remember that we’ve described it kind of as a journey not a destination, and with those similar terms, the notion is that CUSP is your constant building of your culture, of your interest in safety, and your continual review of problems on your unit that could potentially harm a patient. How are we going to fix those problems? It’s engaging your staff on a regular basis and knowing, understanding, truly feeling that they can affect the care that’s being offered. They can influence the level of safety that you’re able to offer to your patients. And so, CUSP is this thing that we want sustained in perpetuity. We’d like to hear 10 years from now that you still have an active CUSP team, and I bet that they’ll still be coming up with ideas for how you can improve care and other things that you can change. We do have CUSP teams here at Johns Hopkins that have been going for 10 years and, all together, we have probably over 40 teams that are operating on all different kinds of units, not just ICUs. So there are opportunities for you to get even more benefit out of your participation in this program by concentrating on trying to share it with your other units within your same institution and also concentrating on how do we keep this ball rolling? How do we keep it rolling well into the future? So did anybody think of something that they would like to share?

Operator: We have a question from Michele Schmite with Stanford Health.

Jill Marsteller: Okay.

Wendell Hoffman: Yeah, this is Wendell Hoffman. I’m the patient safety officer here, and my background is in infectious disease. We have greatly appreciated the CUSP program. We have seen some amazing results in our own institution because of the collaboration that has occurred between our adult PICCU and NICU. We involved our NICU folks. My specific question, though, is regarding sustainability. At Hopkins, how does CUSP fit into your other quality improvement efforts, particularly on the nursing level? There are all kinds of these things going on, safety action teams, advance performing care at the bedside. I mean, there are multiple initiatives. Where does CUSP fit at Hopkins? Has it kind of taken over your quality improvement methodology or structure? How do you view it in light of other things that you’re doing?

Jill Marsteller: Well, for sure there are a number of -- I guess you would call them kind of competing organizing principles or competing programs. A lot of them have very similar goals or similar perspectives on how to improve care. At Hopkins, not every unit, by far, actually has a CUSP team. It is something that has been rolling, that has been moving from one unit to another, but they don’t all have them. There are, indeed, units that are just doing either something else -- I don’t want to say this for sure -- but maybe nothing at all, right? And this is common. I’m sure that this is happening across the country, where there are super-engaged units, and then there are units that are not necessarily as active or engaged in changing and improving care. We do know that in some of our units that are, for floor units, for example, primarily nursing units, we are seeing them use the CUSP program, for example, to address falls, which is a common area that people concentrate on. And so the thing about CUSP is that you can be using CUSP, and then you can have a clinical focus. It’s good to have both a clinical focus and the CUSP program at the same time. The clinical focus really allows people to dig their teeth into something. Sometimes the CUSP program can seem hard to understand, or people are not sure even as they see that there are concrete steps and that you pass through these concrete steps. Sometimes people still feel that it’s just not as concrete as, “Here is a protocol. We are going to implement this protocol. We’re going to change practice.” It’s always good to have a clinical focus at the same time that you are working on a CUSP. But normally, they have identified some kind of a defect, using the staff safety assessment, and they’re addressing that defect, or there was a sentinel event sometimes, or there may be other sources of problems that a specific unit wants to work on. And then within the hospital structure, we have kind of a CUSP program, and any unit or department can come to the patient safety infrastructure we have here, and say, “I want to start a CUSP team.” And then they get a CUSP coach from our quality improvement entity, which is called the Armstrong Institute now, and so then that CUSP coach basically helps them get their CUSP team started, and eventually, over time, they take over that CUSP team themselves and run it completely internally. But we don’t have a policy of making every unit do it, and so there may be other quality improvement activities that are in line with some of the ones you mentioned that are also going on at the same time. I hope that answers your question. It’s not mandated. It is widely used, and in general, people have really felt that it works well in lots of different kinds of units. And so, I guess I would say it’s probably the most prevalent model that’s being used within the Johns Hopkins Hospital. I hope that makes sense to you, Wendell.

Wendell Hoffman: Yeah, it does. We found the model to be, I think, fairly engaging. We certainly have gotten a lot of physicians buy into it, and I would say that we’re now launching forward more intentionally, proposing the defect tool to now be one of the biggest ways in which we hope to sustain change. And it has to be owned at the unit level for this to obviously take place. I was just interested in, there are a number of models out there that address safety issues, and I wondered if CUSP becomes a competitor to other activities that are ongoing, if it comes alongside, where there is nothing in some situations, as you point out. So, yes, it was just basically a general question on where CUSP fits in your quality improvement program at Hopkins.

Jill Marsteller: Well, as far as what is offered centrally that can be requested by any unit, it’s primarily the CUSP program. In addition to that, we have a teamwork and communication program as well, that will tend to focus more on specific communication skills. But those are pretty much the major ones that are centrally offered, yes. So that’s not to say that if somebody wanted to do -- well, that’s sort of changing a little bit. If somebody decided they wanted to do just culture, I think that they would probably be able to do that within their area or unit, except it’s their costs and so on involved, and with the new structure that we have, it may be that they have to kind of get permission to pursue that from the Armstrong Institute. But that’s kind of a new model. I think probably most of the hospitals in the nation are still a little more decentralized than that, in terms of having one program that you kind of call “your thing.” And maybe you guys can do that at Stanford. I would look at the evidence and try to do an evidence-based choice that you think works best for your hospital. We do try to get people to think about how they can make CUSP work with preexisting structures. So many hospitals will already have a quality improvement team and then they join a CUSP project. And so we say, “Okay, maybe you don’t need a separate team. Maybe your quality improvement team, you morph that into your CUSP team. You have them be both if there are other goals that are associated, too. Try to find a way to make this fit with you’ve already got.

Wendell Hoffman: Thank you. At Hopkins, do you have periodic meetings for all your CUSP units? Like do you have a quarterly gathering where you’re doing information sharing and storytelling, your having your in-house speakers, those kinds of things, sort of a centralized/decentralized approach, and then they’re all working on their individual projects? Do you do anything centrally on a periodic basis?

Jill Marsteller: Well, there definitely is a safety council. And it does have people who are either safety officers on each of those units and it includes some of the CUSP coaches and so on. And that committee meets regularly and does what you’re talking about. As far as it has been more like a big retreat of everybody who’s involved in CUSP, to my knowledge, we don’t do anything like that, but I think that’s a great idea. I think that would be really rewarding, and it would really charge everybody up within your institution just as it does when you’re with the rest of your peers from other hospitals at your State meetings. So anyway, I think that’s a great idea. I’ll be looking forward to hearing about how Stanford did it.

Wendell Hoffman: We’re trying to figure it out because we don’t. The strength of CUSP is that it has brought people together around harm, and what we don’t want to do is to ruin something that -- sometimes when you try micromanage something into something bigger, you ruin the beauty of the original model.

Jill Marsteller: Right.

Wendell Hoffman: But at the same time, you want it to spread, and so what we don’t want to do is lose our physicians at the table. Like if we were to morph our current CUSP initiative into a quarterly kind of meeting and then try to get others to come, we’re afraid that we might affect the dynamics at that local meeting. So right now, we’ve spread the CUSP concept to dialysis. We have a CUSP-related VAP group working, also, that both started over the last 5 or 6 months, and we’re in the process of approaching our hemo colleagues, both inpatient and outpatient, at BSIs in their location. So there is both CUSP as a philosophical principle, and then there’s CUSP as related to specific initiatives like with BSIs. So that was kind of my question earlier. How much does CUSP become a philosophical principle that drives overall improvements, since it’s looking at improvements through the lens of risk?

Jill Marsteller: I would say that definitely happens, and it’s definitely true. That’s why I was trying to talk about this idea of expanding from one clinical focus, maintain what you’re doing, and your first clinical focus, let’s say, CLABSI, but then start thinking about some of these other big areas where there is a lot to do. And there’s evidence out there, and you know there is a gap between your own practice and what evidence that you should be doing. And then that can be another focus. And meantime, CUSP is running all along underneath, supporting all of this activity. In a sense, it is a kind of philosophical approach, but also it is a set of concrete steps that you can kind of follow and then reiterate as necessary, right? Go back and redo your staff safety assessment again, if you need to. I think that what you’re trying to do with it, as far as spreading and thinking about how CUSP can be used for either different topics or in additional areas, that’s a great way to try to be sure that you can continue to pay attention to safety. As you said, it’s brought people together around harm. My one thought would be that I don’t think it will spoil it if you try to bring it up to a higher level, just in the sense that maybe the way to start would be looking for issues that everybody’s dealing with. And maybe that’s an appropriate thing to meet on at a higher level anyway. If everybody is having a problem in -- I don’t know -- housekeeping or something, then should every single unit be trying to deal with that separately? Probably not, right? Maybe the right level at which to fix that is a higher level. And so having sort of a unified CUSP team shouldn’t take away from the beauty of the nature of the unit-level CUSP team. It should be something we hope will add some either additional benefit by dealing with a big issue or some social interaction benefits, new ideas kind of benefits. So I appreciate all of your thoughts, Wendell. Thank you for asking or sharing what’s going on at Stanford with us.

Wendell Hoffman: Thank you.

Jill Marsteller: So, we have about 2 minutes left. I’ll just check and see if we have anybody else who had either a question or a comment that they’d like to make.

Operator: Our next question comes from John Bondola with Presbyterian Health Care.

Jill Marsteller: Hi, John.

John Bondola: Good afternoon. I have kind of a basic question about keeping frontline staff involved and engaged in projects. Just trying to be more creative about just having meetings. We’ve found that when we’re on the unit trying to have meetings, just the busyness of the unit, and as we continue to try to improve our productivity, both for the nurses and the physicians, it’s not infrequent there, and there’s time to meet, and that’s great. So what kinds of things are you doing to not just have managers at the meetings but actually have the frontline staff, again, both physicians and nurses involved?

Jill Marsteller: Well, I think that one of the things you have to go in there understanding and expecting is that not everybody is going to be able to attend every one. And I’m sure you already know that. But it’s kind of an understood thing that, “We very much value you here. We’d love to have you here, but if you can’t make it this time, that shouldn’t keep you from coming next time, when you do have a chance.” This kind of very open, please come join, even if it’s for a couple of minutes. Another thing we see a lot of teams doing is kind of having some of their operational meetings more or less on the fly. There will be a person who goes around and talks to several people and comes up with an idea or whatever and then shares it with everybody in an email. So they’ve had to do some of that kind of thing. Making sure that there are backup representatives. Maybe you have a really influential physician, does that person have a very close buddy physician who can go when they can’t go? It’s nice for each member of the team to maybe think about, “Who could I have to sort of offer my point of view on this at this meeting when I can’t be there or at least tell me what happened at the meeting,” and that kind of thing. So get a buzz going where people are sharing what happened in the meeting with those people who couldn’t come. Those are ways to try to keep everybody engaged, and then posting stuff where people get a chance to read it can keep everyone apprised of what’s up and what’s going on. So, unfortunately, there doesn’t seem to be a fabulous solution to the fact that we’re all pretty busy. One of the things, where possible, is to try to see if your hospital can provide resources for at least a couple of members of the CUSP team to have some administrative hours, or that kind of thing, that they’re allowed to contribute toward the project. Something that we really suggest is that you have to have for a nurse champion and a physician champion on your team, but I don’t know to what extent any other administrative hours are available for other people. But if they’re key to the team maybe make an argument that on some basis, could we get them an administrative hour to come to a regular meeting.

John Bondola: That’s helpful.

Jill Marsteller: So hopefully, those are some ideas, and keep thinking about that, everyone. I know that not enough time is a problem for everybody. But, hopefully, that will give you a place to start.

John Bondola: Thanks.

Jill Marsteller: Okay. Well, everyone, we’re a teeny bit over our time, and I want to be respectful of the fact that you have lots of important things to do. So I really appreciate your joining the call, and I know that you’re going to start a new round of calls in January. There are going to be new contact calls, and so I look forward to seeing some of the new material and hearing some of your comments on our new schedule as we start with that next month. In the meantime, I hope everyone has a relaxing winter break and gets a chance to kick back before you jump back into it again with renewed vigor in January. So thank you, everyone, and I’ll talk to you soon.

Female Voice: Happy holidays, and thanks so much Dr. Marsteller. Great presentation and great comments from the participants.

Page last reviewed April 2013
Page originally created April 2013
Internet Citation: Two More “Es” and How To Spread (Transcript). Content last reviewed April 2013. Agency for Healthcare Research and Quality, Rockville, MD.