Stories of Success: Using CUSP To Improve Safety

What Do These Stories Tell Us?

This guide describes how four hospitals are virtually eliminating some HAIs, sustaining their success and making significant inroads in reducing other HAIs. CUSP played a major role in how these organizations converted evidence-based clinical practice into behavior change that was standardized throughout the hospital.

We saw how CUSP doesn't look the same in every organization, and the tools may be used in initiatives with different names. At Shore Health it is called “Target Zero,” and at Saint Joe's it is the “Keystone Team.” NorthCrest used their Lean work to keep going deeper with CUSP: when they had eliminated CLABSI, NorthCrest asked whether they could reduce the number of lines inserted and set a goal to cut 25 percent of that “waste” with the potential for harm the next year. Peterson, which has been without a CLABSI for 32 months as of October 2012, is rolling out CUSP to all hospital departments this same month and will be teaching CUSP to all hospital employees in fall 2012. Although CUSP implementation varied in pace and areas in which it was first applied, a common denominator is that it is a method for front-line staff to identify and fix things that impair safety when they are empowered and supported by their immediate managers and senior leadership.

What common themes emerge from these distinct case studies in which CUSP was applied to dramatically reduce CLABSI and other HAIs? The case studies contain many insights and lessons to assist other organizations in their CUSP journey to mitigate and eliminate harm. Several are important to highlight:

Persistent Leadership Engagement

Eliminating HAIs, sustaining their elimination and creating and maintaining a culture of safety requires strong and ongoing senior leadership. Senior leaders must employ different communication methods depending on the audience. The argument that is most persuasive to clinicians is research data that demonstrate clinical effectiveness of various practice bundles and protocols. Public forums to rally the staff, monthly meetings with adopted CUSP units and private one-on-one conversations with resistant clinicians are all important strategies.

Engaged Leaders and Champions

The cases show us three kinds of leaders and champions supporting or engaging directly with front-line efforts to eliminate HAIs: physician, nursing, and senior administrative champions. Leaders' most significant impact is through being fully supportive of the cultural changes that modify the traditional power balance between physicians and staff by promoting teamwork and collaboration, changing clinical default standards and protocols and empowering staff, especially nurses, to speak up when safety may be compromised.

Getting to Zero Is Possible

CUSP fosters a new way of thinking: HAIs are no longer an unfortunate consequence of care and are preventable. The Michigan Keystone ICU project proved this by getting to a median of zero CLABSIs in the State in the first 18 months of the project onset.

Culture Matters

Though the CLABSI prevention bundle had been available to hospitals for some years, CLABSI rates had not declined. With the addition of the CUSP tools, the technical intervention was readily accepted due to the culture change that CUSP promotes. With CUSP, which offers effective strategies where care is delivered—at the unit level—CLABSI rates did decline significantly throughout the United States. Those interviewed for this guide think of CUSP as a way of life in the hospital, one where silos are eliminated by putting the patient, rather than the department, at the center of the organization.

All Staff Must Own Safety

As long as infections are seen as the responsibility of the infection preventionist and his or her role is confined to tracking and reporting, HAIs will not be eliminated, and likely not notably reduced. Infection elimination belongs to everyone, and the entire hospital staff individually and collectively must own the presence or absence of HAIs.

All Staff Must Be Empowered

To own patient safety, staff members have to be empowered. Empowerment of nursing and other staff requires the support of administrative, nursing, and medical leaders, and once staff are confident that they will consistently have that support, they will be enabled to reduce harm.

Learning Organizations Are Safer

CUSP promotes the mindful learning from defects. It teaches staff to figure out for each identified defect: What happened? Why did it happen (what factors contributed and what prevented it from being worse)? What can we do to reduce the risk of it from recurring with different caregivers? How will we know the risk was reduced? With whom should we share the learning? CUSP also promotes continuous learning about the latest developments in the science of safety. Learning from Defects is a powerful tool to protect future patients from harm and reinforces a key practice in true learning organizations.

Page last reviewed September 2012
Page originally created April 2013
Internet Citation: What Do These Stories Tell Us?. Content last reviewed September 2012. Agency for Healthcare Research and Quality, Rockville, MD.