CUSP for Safe Surgery (SUSP) Kickoff Webinar

DRAFT – final pending AHRQ approval1

CUSP for Safe Surgery (SUSP)Kickoff Webinar

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it is the only thing that ever has.

Margaret Mead

DRAFT – final pending AHRQ approval

Some quick administrative announcements

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You need to dial into the conference line to hear audio

– Dial in Number: 1-800-311-9401

– Passcode: 83762

Please contact your Coordinating Entity for a copy of these slides if you have not already received them

We will make a recording of this webinar available to you

We want you to interact with us today


SUSP Kickoff Agenda

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IntroductionsSUSP Project OverviewBuilding your SUSP TeamIntro to Building and Measuring Safety CultureCurrent Team ExperiencesNext Steps


INTRODUCTIONS

Meet the SUSP National Project Team

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Peter Pronovost, MD, PhD, FCCM

Principal Investigator

Cliff Ko, MD, MS, MSHA, FACS

Principal Investigator

Charles Bosk, PhDPrincipal Investigator

Ethnographer

Sean Berenholtz, MD, MHS, FCCM

State CoachContent Expert


Deb Hobson, RNState Coach

Content Expert

Julius Pham, M.D., Ph.D.State Coach

Content Expert

Liza Wick, MDState Coach

Content ExpertBradford Winters, MD

State CoachContent Expert


Mike Rosen, PhDState Coach

Content Expert

Lisa Lubomski, PhDContent Expert

Sallie Weaver, PhDState Coach,

Safety Culture ExpertChris Goeschel, ScD, MPA, MPS, RN, FAAN

Content Expert


Cathy Van De RuitEthnographer

Ksenia Gorbenko, PhD, MAEthnographer

Not pictured:Jeremiah Bowman

American College of Surgeons

Terry Tsai, PhDSUSP Informatics

Research Manager


Kristine Weeks, MHSSUSP Data Consultant

Tricia Francis, MA, MS, PMPSUSP Project Manager

Kathryn Taylor, RN, MPHSUSP Program Manager Erin Kirley

SUSP Administrative Assistant


Erin Hanahan, MPHSUSP Senior Research

Coordinator

Mary TwomleySUSP Senior Research

Coordinator

Laura Vail, MSSUSP IT Specialist

Nasir Ismail, MSSUSP Safety Culture

Coordinator

Kelsey EdwardsSUSP Research Assistant


Poll – Who is on the call?

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SUSP PROJECT OVERVIEWSEAN BERENHOLTZ, MD, MHS, FCCM

We have embarked on a unique journey.

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Learning Objectives

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After this session, you will be able to:• Distinguish SUSP approach from that of other national

improvement projects• Describe the connection between SUSP and safety

culture work as structured in the Comprehensive Unit-based Safety Program (CUSP)

• List the steps for developing a local SSI prevention bundle



Why is Your SUSP Work Important? 1

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1 in 25 people will undergo surgery

7 million (25%) in-patient surgeries followed by complication

1 million (0.5 – 5%) deaths following surgery

50% of all hospital adverse events are linked to surgery AND are avoidable


Surgical Care Improvement Project (SCIP)2

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Engagement Questions: Feel free to type in the chat!

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In our institution, near perfect compliance with SCIP measures did not result in decreased SSI rates. Have other people on the call observed the same trends?

Why might that be?


What is SUSP?

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AHRQ-funded project– Individual hospitals participate for 2 years

– Participation is free

– Participation is open to any size hospital, in any state, for any surgical procedure type.

Leveraging leaders in field – Armstrong Institute for Patient Safety and Quality, ACS

NSQIP, AHRQ, University of Pennsylvania, WHO


SUSP Enrollment (Cohort 1-3) by Coordinating Entity

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Arkansas Hospital Association Hawaii Safer Care SUSP Collaborative Armstrong Institute for Patient Safety & Quality Iowa Healthcare Collaborative Colorado Hospital Association Maryland Hospital Association Connecticut Hospital Association Michigan Health & Hospital Association Florida Hospital Association Nevada Health Insight Georgia Hospital Association Tennessee Hospital Association


Our Shared Project Goals

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To achieve significant reductions in surgical site infection and surgical complication rates

To achieve significant improvements in safety culture


Key concepts: Adaptive and Technical Work

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TechnicalWork

Adaptive Work

Sweet Spot


Technical Work Adaptive Work

• Procedural components of work, like performing skin prep

• The ‘intangible’ components of work, like ensuring an OR team holds each other accountable for quality skin prep

• Work that we know we ‘should’ do, like letting skin prep dry before incision

• Work that shapes the attitudes, beliefs, and values of clinicians, so they consistently perform tasks the way they know they ‘should’

• Work that lends itself to checklists or protocols

• Culture change is not a checklist

Key concepts: Adaptive and Technical Work


Successful Improvement Work Requires Technical and Adaptive Components

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Reviewed by The Joint Commission3


Comprehensive Unit-based Safety Program (CUSP) is a model to guide adaptive work4

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1. Educate everyone on the science of safety 2. Identify defects3. Senior executive partnership4. Learn from one defect per quarter5. Implement teamwork tools


How is SUSP different?

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Informed by science

Led by clinicians and supported by management

Guided by national and local measures

National implementation that can be tailored to local context


We’re Building on Previous Successes on the State Level…

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Michigan Keystone ICU program– Reductions in central line-associated blood stream

infections (CLABSI) 4,5

– Reductions in ventilator-associated pneumonias (VAP) 6

– Improvements in safety climate 7


…And the National Level

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National On the CUSP: Stop BSI program8

– A national initiative to implement a proven culture change model, CUSP, and interventions to prevent CLABSI.

– A total of 1, 071 ICU’s in 45 states.– A 43% reduction in CLABSI rates.– The number of ICU’s that achieved CLABSI rate of

zero, more than doubled.


Teams reduced hospital-acquired infection rates and improved safety culture

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Safety Climate Teamwork Climate0

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20

30

40

50

60

70

80

90

100

84% 82%

23% 22%

2004 2007

“Needs improvement”: Less than 60% of respondents reporting good safety or teamwork culture

Statewide in 2004, 82-84% needed improvement, in 2007 22-23%7


This improvement model has worked in the ORColorectal NSQIP SSI Rate at Hopkins9

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SUSP is CUSP for Safe Surgery

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This project will teach you to embed adaptive work (CUSP) in your technical work (surgical care).Unlike other SSI prevention projects, you will develop your own SSI prevention ‘bundle.’– There is no one ‘right’ bundle for SSI

prevention– Engage frontline staff to identify local defects


SUSP Project Management Guide

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We have developed monthly modules to guide you through this process.

Each module has ‘deliverables’ for your team, to help you keep your work on track.

Your Coordinating Entity has set up monthly coaching calls to enable horizontal learning.– Please share what you learn on state coaching calls!– You will learn as much (if not more) from each other

as you will from us!


SUSP Project Structure

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Onboarding Phase (Months 1 – 6)– Module 1: Train Everyone on the Science of Safety & Identifying

Defects

– Module 2: Engage Senior Executives in SSI Prevention Work

– Module 3: Debrief your Safety Culture Scores and SSI data

– Module 4: Build your SSI Prevention Bundle

– Module 5: Perform an SSI Investigation

Implementation Phase (Months 7 – 18)

Sustainability Phase (Months 19 – 24)



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Onboarding Phase (Months 1 – 6)

Implementation Phase* (Months 7 – 18) – Module 6: Implementing your SSI Prevention Bundle

– Module 7: Cohort 4 SUSP Team’s Experience

– Module 8: Emerging Evidence: A Surgeon’s Perspective

– Module 9: Learning from Defects I

– Module 10: Learning from Defects II

– Module 11: Optimizing Briefings and Debriefings

– Module 12: Auditing Your Briefing and Debriefing Process *Topics subject to change



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Implementation Phase (Months 7 – 18) – Module 13: SUSP “State of the Union”

– Module 14: Emerging SUSP Topics

– Module 15: Spreading Your SUSP Work


– Module 17: Emerging SUSP Topics


Sustainability Phase (Months 19 – 24) *Topics subject to change



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Onboarding Phase (Months 1 – 6)

Implementation Phase (Months 7 – 18)

Sustainability Phase (bimonthly calls, Months 19 – 24)– Module 19: SUSP Project Sustainability I– Module 20: SUSP Project Sustainability II– Module 21: SUSP Project Wrap-Up


Real Time Feedback (Poll)

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How ready is your organization to 1) enable frontline participation in improvement work and 2) address frontline patient safety priorities?


References

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1. World Health Organization. New Scientific Evidence Supports WHO Findings: A Surgical Safety Checklist Could Save Hundreds of Thousands of Lives. http://www.who.int/patientsafety/challenge/safe.surgery/en/. Accessed August 7, 2013.

2. Centers for Medicare and Medicaid Services. National Impact Assessment of Medicare Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NationalImpactAssessmentofQualityMeasuresFINAL.PDF. Published March 2012. Accessed August 7, 2013.

3. The Joint Commission, Sentinel Event Data. http://www.jointcommission.org/assets/1/18/Event_Type_Year_1995-2011.pdf;29. Accessed August 8, 2013.

4. Pronovost P, Needham D Berenholtz S, et al. An Intervention to Decrease Catheter-related Bloodstream Infections in the ICU. N Engl J Med. 2007;356(25):2660.

5. Pronovost P, Goeschel C, Colantuoni E, et al. Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study. BMJ. 2010; 340:c309.

http://www.who.int/patientsafety/challenge/safe.surgery/en/


References

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6. Berenholtz S, Pham J, Thompson D, et al. Collaborative cohort Study of an Intervention to Reduce Ventilator-associated Pneumonia in the Intensive Care Unit. Infect Control Hosp Epidemiol. 2011; 32(4): 305–314.

7. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Medicine. 2011 May;(39(5):934-9.

8. Website of the National Implementation of the Comprehensive Unit-based Safety Program to Eliminate Health Care-Associated Infections. http://www.onthecuspstophai.org/. Accessed August 7, 2013.

9. Wick et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. J Am Coll Surg. 2012; 215 (2).

10. The Joint Commission. J Qual Patient Saf. 2010;36:252-6http://www.ahrq.gov/cusptoolkit/

http://www.ahrq.gov/cusptoolkit/

http://www.ahrq.gov/cusptoolkit/


BUILDING YOUR SUSP TEAMMIKE ROSEN, PHD

Who is in the room with you?

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Poll

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Do you have a SUSP team?If so, who is on your team?


Learning Objectives

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After this session, you will be able to:• Develop a strategy to engage frontline and executive team

members in SUSP work

• Utilize basic strategies to encourage surgeon participation in SUSP work

• Identify SUSP team members and plan your first meeting


Kevin Driscoll CRNACRNA Lead

Deb Hobson RN“Coach”

Tracie Cometa RNLead RN

Mary Grace Hensel RNManager OR

Sean Berenholtz MDAnesthesia Lead

Lucy Mitchell RNNSQIP SCR

Elizabeth Wick MDSurgery Lead

Renee Demski MBASenior Director QualityJohns Hopkins Medicine

Executive

CoachNSQIPOutcomes

Steph Mullens CSTLead Tech


Perioperative SUSP Team Members

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Essential Team MembersSurgeonsAnesthesiologistsCRNAsCirculating nursesScrub nurses / OR techsPerioperative nursesExecutive partnerNurse leaders

Enhancing Team MembersPhysician assistantsNurse educatorsAnesthesia assistantsInfection preventionistsOR directorsPatient safety officersChief quality officersAncillary staff


The SUSP Team

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• Understands that patient safety culture is local

• Composed of engaged frontline providers who take ownership of patient safety

• Includes staff members who have different levels of experience

• Tailored to include members based on clinical intervention

• Meets regularly (weekly or at least monthly)

• Has adequate resources including protected time– 2 to 4 hours per week for a team leader, surgeon, anesthesia,

nurse, and infection preventionist


Engagement question: Feel free to type in the chat!

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How will you help create 2 – 4 hours of protected time for your SUSP team leaders?


SUSP Teams’ Group Processes

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Effective Group

Processes

Norms

Role Clarity

Effective Team Communication

Conflict Resolution

Education and

Engagement

Leadership Buy-in and

Support


The Senior Executive’s Role

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• Helps the team prioritize improvement efforts• Helps the team navigate organizational bureaucracy• Ensures the SUSP team has resources to fix problems• “Comes out of the office” to meet monthly with members

of health care team in their clinical area


Contacting an Executive Partner

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Contact hospital management to determine which senior executive will best fit the perioperative area and the following criteria:

– Director level or above

– Available to round for at least one hour per month

– Approachable and comfortable with sensitive topics

Set up a meeting to introduce the project, provide a tour of the perioperative area, and share unit-level information


The Surgeon Leader’s Role• Serves as role model for SUSP activities

• Meets with SUSP team at least monthly

• Participates in monthly senior executive partnership meetings

• Communicates with physician group as needed

• Assists with implementation of interventions


Engage Surgeons on the SUSP Team

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Identify surgeon leaders

Create an understanding

of this role

Develop a plan for

communications

Listen to surgeon concerns

Develop plans to address concerns

Reward surgeon leaders

Create a vehicle for

communication


Practical Tips for Scheduling Your SUSP Meetings

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Incorporate SUSP meetings into ongoing educational activities to ease scheduling challenges– Regularly scheduled nurse training– Grand rounds for physicians– Invite RNs to joint grand rounds

Create incentives for participating


You have access to some helpful tools

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CUSP for Safe Surgery Team Roles and Responsibilities Form

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Next Steps:

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• Recruit a team lead, nurse lead, surgeon lead, and executive partner along with other team members

• List team member names and contact information on the CUSP for Safe Surgery Team Member Form and post the form in a central location

• Schedule your SUSP meetings– Complete CUSP for Safe Surgery Roles and

Responsibilities Form during your first meeting


Real Time Feedback (Poll)

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Do you think that your team can influence your organization 1) enable frontline participation in improvement work and 2) address frontline patient safety priorities?


AN INTRODUCTION TO BUILDING AND MEASURING SAFETY CULTURESALLIE WEAVER, PHD

The “adaptive” glue that helps bond safe teams

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Learning ObjectivesAfter this session, you will be able to:• Define safety culture

• Describe why safety culture is important for improvement efforts

• Describe the SUSP safety culture measurement process


What is Safety Culture? Perceived priority of safety relative to

other goals

Culture is the compass team members use to guide their behaviors, attitudes, & perceptions on the job

• What will I get praised for?• What will I get reprimanded for?• What is the “right” thing to do?

Culture provides the context for team success

Image source: Marysia Tomaszewska, August 8, 2012, used under a Creative Commons License

http://wilkolak3dh.deviantart.com/

http://wilkolak3dh.deviantart.com/


What Are the Core Aspects of Safety Culture…

Schein, 2007


Why Safety Culture Matters1. Safety culture is related to outcomes

– Patient outcomes Patient care experience Infection rates, sepsis Postop. hemorrhage, respiratory failure, accidental

puncture/laceration Treatment errors

– Clinician outcomes Incident reporting, burnout, turnover

Huang et al., 2010; Mardon et al., 2010; MacDavitt et al., 2007; Singer et al., 2009; Sorra et al., 2012; Weaver, 2011.


Why Safety Culture Matters2. Safety culture influences the effectiveness of other

safety and quality interventions

– Can enhance or inhibit effects of other interventions

3. Safety culture can change through intervention

– Best evidence so far for culture interventions that use multiple components

Haynes et al., 2011; Morello et al., 2012; Van Nord et al., 2010; Weaver et al., in press


CUSP & Safety Culture

We ask that you measure safety culture at the start of the SUSP project– Provides a baseline to diagnose barriers and facilitators that can

impact improvement efforts– Then can be measured 12-18 months following start of

improvement efforts

Use reliable and valid survey instrument– Hospital Survey on Patient Safety (HSOPS)

CUSP is the intervention that you will use to help you improve culture results


Example: HSOPS Questions & Composite Scores

10 Composite Scores (“Dimensions”)

No. of Questions

Example Question

1. Supervisor/manager expectations & actions promoting patient safety 4 B1. My supervisor/manager seriously considers

staff suggestions for improving patient safety.

2. Organizational learning-continuous improvement 3 A9. Mistakes have led to positive changes here

3. Teamwork within unit 4 A1. People support one another in this unit.

4. Communication openness 3 C4. Staff feel free to question the decisions or actions of those with more authority.

5. Feedback & communication about error 3 C1. We are given feedback about changes put into place based on event reports.

6. Nonpunitive response to error 3 A8. Staff feel like their mistakes are held against them. (negatively worded)

7. Staffing 4 A2. We have enough staff to handle the workload.

8. Hospital management support for patient safety 3 F8. The actions of hospital management show that

patient safety is a top priority.

9. Teamwork across hospital units 4 F4.There is good cooperation among hospital units that need to work together.

10. Hospital handoffs & transitions 4 F5.Important patient care information is often lost during shift changes. (negatively worded)


HSOPS Questions & Composite Scores (cont’d)

6 Background questions

4 Outcome Variables No. of Questions

Example Question

1. Overall perceptions of safety 4 A15. Patient safety is never sacrificed to get more work done.

2. Frequency of event reporting 3 D1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?

3. Patient safety grade (of hospital unit)

1 E1. Please give your work area/unit in this hospital an overall grade on patient safety.

4. Number of events reported in the last 12 months

1 G1. In the past 12 months, how many event reports have you filled out and submitted?


HSOPS Scoring

Scoring guidelines created by AHRQ

Scores represent the % of positive responses– % who gave a score of 4 or 5


Drawing from existing data: Some important questions

Has data about the safety culture in our work area been collected in the last 12 months? If yes:

When was this data collected and how (e.g., online survey, paper survey, in person interviews)?

Who has access to this data?

What aspects of culture were measurement/what data were captured?

Is it possible to obtain copies of the raw data (e.g., an excel file of responses) or only reports (e.g., pdf file with charts and graphs)?


Your HSOPS Survey Coordinator Has a Key Role

Helping coordinate the HSOPS survey administration processParticipating in training webinars and conference call to learn how to use the SUSP Online Portal Informing clinicians and staff about the survey items and instructions; assisting them if they have questions about how to complete the online surveyEntering data about the work area(s) that will be completing the HSOPS survey into the SUSP Online PortalMonitoring the survey response rate using the SUSP Online PortalWorking with hospital and work area leadership to distribute survey materials and information


Next StepsComplete the SUSP Portal Registration Form if you have not already done soIdentify an HSOPS Survey coordinator to attend a training call on October 28th (10-11am EST) or October 30th (2-3pm EST)Determine if your hospital has recently completed a safety culture survey


ReferencesHaynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Dziekan G, Herbosa T, Kibatala PL, Lapitan MC, Merry AF, Reznick RK, Taylor B, Vats A, Gawande AA; Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf. 2011 Jan;20(1):102-7.Huang DT, Clermont G, Kong L, Weissfeld LA, Sexton JB, Rowan KM, Angus DC. Intensive care unit safety culture and outcomes: a US multicenter study. Int J Qual Health Care. 2010 Jun;22(3):151-61. MacDavitt K, Chou SS, Stone PW. Organizational climate and health care outcomes. Jt Comm J Qual Patient Saf. 2007 Nov;33(11 Suppl):45-56.Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf. 2010 Dec;6(4):226-32.Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf. 2012 Jul 31. [Epub ahead of print]Schein E. Organizational culture and leadership, 4th edition. San Francisco, CA: Jossey-Bass. 2010.


ReferencesSinger SJ, Falwell A, Gaba DM, Meterko M, Rosen A, Hartmann CW, Baker L. Identifying organizational cultures that promote patient safety. Health Care Manage Rev. 2009 Oct-Dec;34(4):300-11.Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring Relationships Between Patient Safety Culture and Patients' Assessments of Hospital Care. J Patient Saf. 2012 Jul 10. [Epub ahead of print].Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.van Noord I, de Bruijne MC, Twisk JW. The relationship between patient safety culture and the implementation of organizational patient safety defences at emergency departments.. Int J Qual Health Care. 2010 Jun;22(3):162-9.Weaver SJ. A configural approach to patient safety climate: The relationship between climate profile characteristics and patient safety. Doctoral dissertation. University of Central Florida. 2011.Weaver, S. J., Dy, S., Lubomski, L., & Wilson, R. Promoting a culture of safety. In R.M. Watcher, P.G. Shekelle, P. Pronovost (Eds.). Making healthcare safer: A critical analysis of the evidence of patient safety practices (AHRQ report # TBD). Rockville, MD. In press.


CURRENT TEAM EXPERIENCESUNIVERSITY MEDICAL CENTER SOUTHERN NEVADA

Hear from SUSP Teams who have gone before.


NEXT STEPSKATHRYN TAYLOR, RN, MPH

We’re in this together.


Poll

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Give us your best guess: What percentage of organizational change efforts fail?


Preparing to Lead

In a postmortem, an autopsy is performed to learn why a patient died. While it may be helpful to those who perform it and hear about the results, it does not help the central figure in the medical drama—the patient.

The PreMortem Exercise is used to identify potential barriers and vulnerabilities to project success before they occur. It builds intuition and sensitivity to future problems.


Step 1

Imagine that we are 2 years into the future and, despite all of the team’s efforts, the project has failed—catastrophically. Things have gone completely wrong on a number of fronts.

Now, ask: – What does the worst case scenario look like?


Step 2

Generate the reasons for failure.

Spend the next 10 minutes writing down all the reasons you believe this failure occurred.

Now, ask: What could have caused our project to fail?


Step 3

Prioritize your list of potential reasons for failure.

Address the top 2 or 3 items from your list that are of greatest concern.

Now, ask:– What specific actions can you take to avoid or

manage these issues?


Step 4

Throughout your project, periodically review the potential problem list to re-sensitize yourself and the other team members to problems that may be emerging.


Premortem Summary

Step 1: Two years out, what does the worst case scenario look like?Step 2: What could have caused your project to fail?Step 3: What specific actions can you take to avoid or manage these issues?Step 4: Review and resensitize yourself to potential problems throughout the project.

79 DRAFT – final pending AHRQ approval

You can access project planning resources on the SUSP Portalhttps://armstrongresearch.hopkinsmedicine.org/susp.aspx

Coaching call schedule for your Coordinating Entity

SUSP Project Management Guide

CUSP for Safe Surgery Team Membership Form and CUSP for Safe Surgery Roles and Responsibilities Form

Webinar archives

https://armstrongresearch.hopkinsmedicine.org/susp.aspx

https://armstrongresearch.hopkinsmedicine.org/susp.aspx


WRAP UP

How will the SUSP Project look in your hospital?


A Summary of Your Next Steps

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• Return SUSP Portal Registration Form if you have not already done so• Identify an HSOPS Survey coordinator to attend a training call on

October 28th (10-11am EST) or October 30th (2-3pm EST)

• Schedule your SUSP meetings• List team member names and contact information on the CUSP

for Safe Surgery Team Membership Form and post the form in a central location

• Complete CUSP for Safe Surgery Roles and Responsibilities Form during your first meeting

• Complete the pre-mortem exercise and share your findings during a coaching call.


On the Next Call

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What questions do you have?

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Remember you have a support network– You can ask questions during coaching calls

– You can contact the SUSP helpdesk

SUSP Helpdesk: [email protected]


Kickoff Webinar Evaluation

https://www.surveymonkey.com/s/SUSP_Cohort4

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CUSP for Safe Surgery (SUSP) Kickoff Webinar

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