Professional Documents
Culture Documents
Success
1
Working Together – The Players
2
Learning Objectives
3
ICU Safety Climate
Effect of CUSP on Safety Climate
100
87
% "Needs Improvement" *
90
80
70
60
50 47
40
30
20
10
0
Pre vs. Post Intervention
5
Attribution: J. Bryan Sexton
Teamwork Climate &
100
Annual Nurse Turnover
90
% reporting positive teamwork climate
80
70
60
50
40
30
20 High Turnover 16.0% Mid Turnover 10.8% Low Turnover 7.9%
10
0
• Execute
– Standardize: Create line cart
– Create independent checks: Create BSI checklist
– Empower nurses to stop takeoff
– Learn from mistakes
• Evaluate
– Feedback performance
– View infections as defects
7
Ensure Patients Reliably Receive
Evidence
Senior Team
Staff
leaders leaders
Engage How does this make the world a better place?
Educate What do we need to do?
What keeps me from doing it?
Execute
How can we do it with my resources and culture?
CUSP
Comprehensive Unit-based Safety (TRiP)
Program Translating Evidence Into Practice
9 Improve
What is CUSP?
www.onthecuspstophai.org
10
On the CUSP: Stop BSI
Intervention
13
Pre CUSP Work
14
Steps of CUSP
2. Identify defects
15
Pronovost J, Patient Safety, 2005
Step 1: Science of Safety
• Understand system determines performance
16
Step 2: Identify Defects
17
Prioritize Defects
• Discuss with staff what are the three greatest risks and
what you should work on first
18
Step 3: Executive Partnership
19
Step 4: Learning from Mistakes
• What happened?
• Why did it happen (system lenses)?
• What could you do to reduce risk?
• How do you know risk was reduced ?
– Create policy, process, or procedure
– Ensure staff know policy
– Evaluate if policy is used correctly
20
Pronovost 2005 JCJQI
Step 4 cont’d: Identify Most Important
Contributing Factors
• Rate each contributing factor
21
Step 4 cont’d: Identify Most
Effective Interventions
22
Step 4 cont’d: Evaluate Whether Risks
Were Reduced
23
Step 5: Teamwork Tools
• Call list
• Daily goals
• Morning briefing
• Shadowing
• Culture check up
24
Pronovost JCC, JCJQI
Step 5 cont’d: Call List
25
Step 5 cont’d: Morning Briefing
26
Step 5 cont’d: Shadowing
27
CUSP is a Continuous Effort
28
Action Items -- CUSP
29
References
• Thompson DA, Holzmueller CG, Cafeo CL, et al. A morning briefing: Setting the
stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005;
31(8):476-479.
30