The Basics of the Comprehensive The Basics of the Comprehensive Unit-Based Patient Safety Program Unit-Based Patient Safety Program

(CUSP) (CUSP)

Pat Posa RN, BSN, MSASystem Performance Improvement LeaderSt. Joseph Mercy Health SystemAnn Arbor, MIpatposa@gmail.com

Coaching Call 2: Staff Safety Assessment; Measuring Culture

2/21/2012

THEBASICS OF CUSP

Kimberly O’Brien, MHA

Director, Program Development

Missouri Center for Patient Safety

Jefferson City, MO

kobrien@mocps.org

Coaching Call 2, Document 1

1

Before We Get Started . . . A Few Housekeeping Items

• Post-coaching call surveys– Team leader will receive by email following each coaching call– Team leader must complete each one

• Team leaders should attend coaching calls

2

Before We Get Started . . . A Brief Recap of Coaching Call 1

(1/17/2012)• Overview of CUSP (6 steps)• Structure of this training program

– 6 coaching calls– Each coaching call will cover 1 or 2 steps of CUSP– Team leaders will have homework after each call to implement each step

• Coaching Call 1 Team Lead Checklist– Choose a unit to implement CUSP– Recruit a CUSP team and executive sponsor– Schedule CUSP team meetings for 6 months or more– Team leads and team members listen to/view the Physician Engagement and

Science of Safety videos– Facilitate first team meeting (for teams that are established)– Complete post-coaching call survey

3

The “Secret Ingredient”Comprehensive Unit-Based Patient

Safety Program1. Form a unit CUSP team with executive

sponsorship2. Measure unit culture3. Educate staff on Science of Safety4. Identify defects using the Staff Safety

Assessment; prioritize defects5. Learn from one defect per quarter6. Implement team/communication tools

4

Step 3: Educating Staff on the Science

of Safety

5

Review from Session 1: Understanding the Science of Safety

• How can errors happen?– People are fallible– Medicine is still treated as an art, not science– Need to view the delivery of healthcare as a

science– Need systems that catch mistakes before they

reach the patient

6

Review from Session 1: Understanding the Science of Safety

• How can we improve?– Every system is perfectly designed to achieve the results it

gets– Understand principles of safe design

• standardize, create checklists, learn when things go wrong– Recognize these principles apply to technical and team

work– Teams make wise decisions when there is diverse and

independent input

Caregivers are not to blameCaregivers are not to blame

7

Methods to Educate on Science of Safety

• Content:– Josie King DVD or share own hospital story– “Science of Safety” video by Peter Pronovost, MD from

Johns Hopkins University– We provided you with three presentations that you can

select slides from or use as is• Have the CUSP team make final decision on content– Couple of team members put it together and present to

CUSP team– CUSP team provides input and decides on final product

that will be used to educate all staff

8

Key Messages to Include

• Safety is everyone’s responsibility• Mistakes are usually the result of system and

process issues—improving those will improve safety

• Improving culture will positively impact safety• Remember the human factor—we all make

mistakes---our job is to identify risks and put in place processes to mitigate that risk

9

Strategies to Educate on Science of Safety

• Delivery Strategies– 30 minutes in length– Mandatory for all staff– Provided on all shifts to all providers– Reminders and reinforcement in daily huddles

• Consider having staff complete the Staff Safety Assessment at the end of the education session– Place completed assessment in envelope or box

• Track Attendance• Discuss how to educate new staff on science of safety

10

Step 4:Staff Safety Assessment:

Identifying Defects

11

Staff Safety Assessment

• What is it?• Why is it important?• What is the CUSP team going to do with the

information?

12

Staff Safety AssessmentWhat is it?

• Two questions for bedside staff:– Please describe how you think the next patient in

your unit/clinical area will be harmed– Please describe what you think can be done to

prevent or minimize this harm

13

Staff Safety AssessmentWhy is this Important?

• Frontline staff are the best people to identify safety issues

• By asking them what the issues are, responding to their issues, and including their wisdom to develop solutions they become a part of improving safety on the unit

• Staff will begin to understand their role and responsibility in the safety on the unit

14

Staff Safety AssessmentWhat is the CUSP team going to do with this data?

• Collate the data • Identify issues/themes• Prioritize an issue/defect to resolve using the

Learn from a Defect Tool

15

Timeline for Science of Safety Staff Education and Staff Safety Assessment

• 2/22 to 3/1/2012: Plan content and set up in-service schedule for Science of Safety Education and Staff

Safety Assessment

• 3/1 to 3/16/2012: Conduct in-services and administer Staff Safety Assessment questionnaire

• 3/16 to 3/23/2012: Collate results of Staff Safety Assessment

questionnaire16

Step 2: Measuring Unit Culture

17

Why Measure Unit Culture?

• Determine how bedside staff are feeling related to communication and recognizing defects– Diagnose and assess the current status of patient safety culture.– Identify strengths and areas for patient safety culture improvement.– Examine trends in patient safety culture change over time.– Measure/evaluate the cultural impact of patient safety initiatives and

interventions.

• CUSP is the intervention that will help you improve culture results– Results will be discussed during coaching call 5 – unit culture action plan

development

18

AHRQ’s Hospital Survey on Patient Safety (HSOPS)

42 items assess 12 dimensions of patient safety culture

1. Communication openness

2. Feedback & communication about error

3. Frequency of event reporting

4. Handoffs & transitions

5. Management support for patient safety

6. Nonpunitive response to error

7. Organizational learning--continuous improvement

19

AHRQ’s Hospital Survey on Patient Safety (HSOPS)

8. Overall perceptions of patient safety

9. Staffing

10. Supv/mgr expectations & actions promoting patient safety

11. Teamwork across units

12. Teamwork within units

Patient safety “grade” (Excellent to Poor)

20

HSOPS Process• Each Team Leader must identify how many staff members on the unit will

be surveyed – all staff should take the survey!– Physicians– Licensed Staff – RNs, RTs, LPNs, etc.– Non-licensed Staff – CNAs, Unit Clerks, Housekeepers, etc.

• Team leaders will be asked to provide this information in the post-coaching call 2 survey (will be emailed to you on March 2, 2012)

• MOCPS will email a URL/link to each Team Leader– team leaders will distribute this link to all staff targeted to take the survey

• The survey will be open between April 2nd and April 30th, 2012• Goal is reaching a 60% response rate• Results will come into MOCPS – reports will be sent to each team leader

21

HSOPS Process: If the unit has recently completed a

safety survey• If units have already taken a patient safety culture survey and

the following is true:– A) survey occurred within the last 6 months– B) unit received at least a 60% response rate– C) there have been no major staff, leadership, or structural changes in the unit,

such as• Staff turnover/layoffs• Changes in medical staff or medical staff model (i.e. open vs. closed unit)• Change in manager

. . . then you do not need to take it again – those results can be used for the action planning we will do in Coaching Call 5

22

HSOPS Process: Getting a 60% Response Rate

• Value it!• Explain to staff why filling out the survey is so important – showcase

specific examples from the unit that help validate that culture improvement is important for all staff

• Make the survey accessible to all staff– Email the URL vs. Putting URL on one computer accessible to all staff – both are options

• Make it a challenge – if the unit reaches 60%, get some sort of incentive (i.e recognition, small gift, pizza or ice cream party, etc.)

• MOCPS will send weekly response rate reports during the 3-week survey period

23

What are your next steps?

• Conduct First or Second team meeting

• Educate team on the Science of Safety and Staff Safety

Assessment; establish plan on how to roll out to unit staff and execute

• Review HSOPS tool and define process for administration

24

Module 1: The Basics of CUSP• Session 1: Forming a CUSP team and

Science of Safety Education• Session 2: Staff Safety Assessment and

Measuring Culture• Session 3: Learning from a Defect-part 1• Session 4: Learning from a Defect-part 2• Session 5: Safety Culture Results and

Action Planning• Session 6: Evidence-based Practice, Just

Culture and CUSP team tools

25

Be Courageous

We all are responsible for the safety of our patients----Own the issues

•“If not this, then what??”•“If not now, then when?”•“If not us, then who??”

26

Notes on Hospitals: 1859

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

Florence Nightingale

27

Advocacy = Safety

A Healthcare Imperative

“In medicine, as in any profession, we must grapple with systems, resources, circumstances, people-and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, we must improve.”

Atul Gawande in his book, Better: A Surgeon’s Notes on Performance

28

Questions?

29