The Organizational Embrace of CUSP to Improve Patient Safety

1. CLABSI Supplemental Call Series The Organizational Embrace of CUSP to Improve Patient Safety Tuesday, March 202:00pm ET/1:00pm CT

2. Session Objectives • To relate an organization’s approach to implementing CUSP in multiple areas of the hospital to reduce harm beyond CLABSI and CAUTI, and to improve the overall culture of safety. • To discuss the mechanics at the hospital level of standing up and supporting the CUSP teams.

3. Today’s Speakers Holy Cross Hospital Silver Spring, MarylandYancy Phillips, MD, MACP, Vice President Quality and Care ManagementSean Maxwell, Lead Angiography TechnicianUpper Chesapeake Health Havre de Grace and Bel Air, MarylandJim Hursey, MBA, Sr. VP, COOJudi Webster, RN, BSN, PI Patient Safety Coordinator

4. Holy Cross Hospital CUSP Beyond the ICUHoly Cross HospitalSilver Spring, MarylandYancy Phillips, MD, MACP, Vice President Quality and Care ManagementSean Maxwell, Lead Angiography Technician

5. Today’s Agenda • A little about us • CUSP Teams as the lever • HCH CUSP Team approach • Interventional radiology CUSP • Resilience • Connecting the dots

6. Holy Cross Hospital • Member of Trinity Health • Largest hospital in MD-DC suburbs • Founded 1963 • Primarily serves Montgomery and Prince George’s counties • Montgomery County’s only teaching hospital for medical education • 455 licensed beds, including 46 in the NICU • 1321 Medical staff and 3062 Employees • FY11 Annual discharges 33,210 • Outpatient registrations 170,317 • Surgeries 13,281 • Emergency center 88,121

7. HCH Patient Safety Initiatives • Peri-natal Patient Safety Initiative • Stamp Out Sepsis campaign • Hiring experienced nurses • ICU multi-disciplinary rounds • Mandatory influenza immunization • OR universal protocol • Patient Safety Committee • Root Cause Analysis, FMEA • Fall prevention • Etcetera, Etc, Etc……

8. December 2010 AHRQ Survey

9. Fall 2010 • Duke Patient Safety Course • December 2010 AHRQ Survey • Maryland Hospital Association • CLABSI-CUSP Collaborative • Make CUSP teams the tool • Invite Bryan Sexton to Holy Cross

10. Comprehensive Unit-Based Safety Program (CUSP) • Focus on local processes and “defects of care” • Frontline patient safety leader (PSL) • Area manager • Physician champion • Executive partner • Frontline staff • Other key personnel (e.g., RT in ICU)

11. Selecting CUSP Teams • CLABSI-CUSP Collaborative • SICU and ICU/CCU • Lower perception of safety scores • Pharmacy, Gen Surg, OR, Medicine, PCU, ER • Paired Units • IMC/CIC and HRP/L&D • Recent significant events • Interventional Radiology • Inpatient units without CUSP Teams • Joint & Spine, Womens’ Surgery, Oncology, ASD • Maternity, NICU, Peds, Observation

12. April 2011 Three day patient safety training – 94 individuals Five one hour frontline staff patient safety sessions Grand Rounds on Patient Safety Medical Executive Committee dinner “Safety as a System” video at orientation and on HCH intranet

13. CUSP Teams PCU Gen Surg 11 CUSP Teams representing 14 units and 68% of frontline staff IMC/CIC 5 Medicine Pharmacy SICU Emer Center L&D and HRP ICU/CCU OR IntRad

15. CUSP Team Activities • Team meets 1-2 times per month • Separate Executive Rounds with PSL • Work on a few defects at a time • Hand hygiene • Hand offs and transitions in care • Patient identification • Standardization of care practices • Supplies and equipment • Orders management • Protected time for PSL • CUSP All Teams Meeting

16. Learning From Defects What happened? Brief defect description Why did it happen? System factors, e.g staffing, workload, equipment, production pressure, training, fatigue, physical environment, etc. What can we do to reduce the risk of it recurring with different caregivers? How will we know the risk was reduced? With whom should we share our learning?

17. Directed Defects Work • Hand Hygiene • One hour per month “secret shopper” from each PSL for 3 months • CLABSI—critical care units • CAUTI—med/surg units • CLABSI/VAP/CAUTI defects tool--ICUs

18. Protected Time for PSL • Budgeted up to 12 hours per month • Charged to Patient Safety • Schedule with manager • Have a plan for the time • Shadowing on unit • Shadowing off unit • Direct observation • Peer interviews • Defects of Care • Data collection • Send summary of day’s activity to Dr. Phillips

19. CUSP All Teams Meeting • Bi-monthly at two different times and days • PSLs, managers and physicians • Review tools and reports • Review protected time use • Share experiences and barriers

20. Interventional Radiology CUSP • Medication errors • Emphasize double verification • Direct observation • High alerts meds JIT • Outdated devices • Inventory label alert • Double confirmation • Consents • Protected Time

21. Sustaining CUSP • Maturing Patient Safety Leaders (PSLs) • Using protected time • Protecting the CUSP charter • Engaging physicians and executives • Using the tools without a CUSP team • Chartering new CUSP teams • Training new team members • Keeping organizational focus

22. Focusing Our Organizational Efforts • Key Outcomes • Actively Engaged Staff • Overall Perception of Safety • Key Drivers • Communication Openness • Staff Burnout

23. Organizational Initiatives • CUSP Teams • Staff retention and performance • Pay structure and clinical ladder • Decreased agency • Web-based error reporting system • Just Culture Principles • Resilience Resource Team

24. Resilience • Is an ability to recover from or adjust easily to misfortune or change • Is the ability to become strong, healthy, or successful again after something bad happens • 4 Fs--Friends, Family, Faith, Fitness • Resilience Resource Team • to identify, organize and communicate about existing resources to combat burnout • to develop new initiatives that increase resilience.

25. Connecting the Dots Just Culture Open Communication Resilience CUSP Teams Actively Engaged Staff Staff Retention Patient Safety

26. Upper Chesapeake Health, Maryland Jim Hursey, MBA, Sr. VP, COO Judi Webster, RN, BSN, PI Patient SafetyCoordinator

27. Upper Chesapeake HealthMaryland • 2 Acute care, not-for-profit hospitals - Upper Chesapeake Medical Center in Bel Air and Harford Memorial Hospital in Havre de Grace, 30-40 miles northeast of Baltimore. • Affiliated with the University of Maryland Medical System • Total of 272 licensed beds and combined total of over 90,000 ED visits and 1,400 Deliveries annually • Almost 3,000 Team Members and over 600 Medical Staff physicians

28. Senior Leadership Commitment • Establish the Culture of Safety • Senior Leadership support is the key to success • Set Expectations for Leaders and Team Members • Patient Safety incorporated into the Culture of Excellence philosophy and Strategic Plan • Starts in Orientation of New Team Members • Jose King video for all TM • Science of Safety video for clinical and Security TM • Insure Administrative Polices are in place to support a Culture of Safety and Just Culture • Stop the Line Policy

29. Senior Leadership Commitment • Facilitate Improvements by providing resources • Support non-productive time for participation in Collaborative meetings, Conference Calls, Education and Data Gathering for frontline TM and Leadership • Model Behaviors important to the Culture of Safety • Support Speak-Up and provide non-threatening environment • Participate in Patient Safety Walkabouts and Collaborative Executive Rounding • Listen to TMs

30. Our Journey • Started biannual Patient Safety “Walkabouts” in the Summer of 2010 in all departments and nursing units as part of the evidenced-based Patient Safety Initiative. • Introduced the concept of Patient Safety Walkabouts and presented short agenda of “Hot Topics” • To stimulate open discussion, we used the results of AHRQ Culture of Safety Survey completed in December 2009

31. Our Journey • CUSP:CLABSI Collaborative Project started November 2010, calling for monthly rounds in ICU’s. • Used Staff Safety Assessment as the basis for initial talking points for Sr. Leadership to create a less threatening environment. • Open forum for discussion of concerns

32. Flexibility is a Necessity • Began by scheduling 1 hour in each ICU, at each facility, every month • Difficult for Sr. Leaders scheduling • “Schedule-Keeper” needs to understand the importance of making Walkabouts a priority. • 60 minutes is too long for all involved – clinical TM could not be away from patients that long, Leaders running to next meeting – very stressful for all

33. Current Process • Monthly ICU rounds • 30 minute sessions, can accomplish everything in about 20 minutes on the ICU’s • Quarterly rounds to remainder of Departments/Nursing Units • Invite all TM to participate – EVS, Dietary, Rehab, Respiratory and Vascular Access Team, etc are encouraged to participate in Walkabouts on the Nursing Units when they are there – dates and times advertised and sent to Managers and Directors for communication. • All levels of leadership and PI Patient Safety Coordinator participate • Use a Grid to track issues

34. Accountability- The Grid • Created a spreadsheet for each unit/department • PI Patient Safety Coordinator records all issues presented and maintains the Grid • Leadership is assigned to follow-up on the item, their VP notified • Target completion dates are assigned • Spreadsheet is emailed to all Leaders for their follow-up and posting in each unit/department TM common area • Some issues (process) are referred to Unit-Based Nurse Practice Councils or the larger Nurse Practice Council for resolution. • Leaders send updates for the spreadsheet as items/issues are resolved • Leaders responsible for communicating Grid to TM

35. Sample Walkabout Grid

36. Walkabout Agenda • Short agendas are good! • We start with a topic that is a Patient Safety goal • “Hot Topics” • Share stories • Review status of Open Issues from previous visits • Open Discussion of TM Patient Safety Concerns • Listen to all concerns, • Ask for solutions • Charge Nurse Phones & Alarm Fatigue • RRT Responders Medication Access

37. Final Thoughts • It’s a marathon, not a sprint • Find what works for you and your culture • Involve Physician Leadership • Value Team Members – they have lots of great ideas!

38. Your Feedback is Important! https://www.surveymonkey.com/s/Z6FJ28T

39. Questions