© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Comprehensive Unit Based Safety Program(CUSP)

Elizabeth C. Wick, M.D.

BackgroundNSQIP report 2009

5

Johns Hopkins

Comprehensive Unit-based Safety Program (CUSP)

– Educate and improve awareness about patient safety and quality of care to ALL PROVIDERS (techs, nurses, anesthetists, surgeons, residents)

– Empower staff to take charge, put their local wisdom to use, and improve safety in their work place

• Their voice NEEDS to be heard

– Partner unit with an actively participating hospital executive

• Send a message to frontline staff about the importance of the work

• Provide resources for unit improvement efforts

• Hold team accountable for improvement

– Provide tools to monitor outcomes, investigate and learn from defects and improve teamwork and safety culture

Successful Efforts to Reduce Preventable Harm

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

stream infections (CLABSI) 1,2

– Reductions in ventilator-associated pneumonias (VAP) 3

• National On the CUSP: Stop BSI program

1. N Engl J Med 2006;355:2725-32. 2. BMJ 2010;340:c309. 3. Infect Control Hosp Epidemiol. 2011;32(4): 305-314.

CUSP for Surgery

Comprehensive Unit Based Safety Program

Component1. Science of safety education

2. Safety culture assessment

3. Senior executive partnership

4. Safety Assessment

5. Implement teamwork and communication tools

Armstrong Institute for Patient Safety and Quality

Patient Safety Culture

• Domains of Culture• Speaking Up• Job Satisfaction• Burnout• Perceptions of Management• Working Conditions• Teamwork

Makary M, et al., Annals of Surgery, 2006

Perceptions of Teamwork Vary Among Operating Room Providers

Armstrong Institute for Patient Safety and Quality10

Makary et al. JACS 2006

COLORECTAL SURGERY CUSP

Armstrong Institute for Patient Safety and Quality

Kevin Driscoll CRNACRNA Lead

Deb Hobson RN“Coach”

Tracie Cometa RNLead RN

Sean Berenholtz MDAnesthesia Lead

Lucy Mitchell RNNSQIP SCR

Elizabeth Wick MDSurgery Lead

Renee Demski MBASenior Director QualityJohns Hopkins Medicine

Executive

NSQIPOutcomes

Steph Mullens CSTLead Tech

What are the safety problems?

Safety Issue Identified(% response)Infection Control (68%)

Coordination of Care (12%)

Communication and Teamwork (12%)

Equipment/ Supplies (2%)

Policies/Protocols (2%)

Education/Training (2%)

Wick et al. JACS, 2012, in press

Gentamicin

Interventions:• Increased amount of

gentamicin available in the room

• Added dose calculator in anesthesia record

• Educated surgery, anesthesia and nursing in grand roundsDespite >95% compliance on SCIP

Armstrong Institute for Patient Safety and Quality

Skin Preparation

Interventions:• Chlorehexidine wash cloths given to patients pre-

operatively

• Surgical skin preparation standardized to chloraprep(even in patients with ostomies)

• Prep responsibility shifted to circulating nurse from resident

• All nurses trained on chloraprep applicationArmstrong Institute for Patient Safety and Quality

Normothermia

Interventions:• Confirmed that

temperature probes were accurate (trial comparing foley and esophageal sensors)

• Initiated forced air warming in the pre-operative area

Armstrong Institute for Patient Safety and Quality

Separation of “Dirty” and “Clean”Instruments

Intervention:• Built separate tray of

instruments used for bowel anastomosis

• Extra suction and bovie tip and gloves opened and changed after anastomosis

• Educational sessions with scrub techs and nurses about instrument separation

• Audits and education on the spot

0

5

10

15

20

25

30

35

40

45

Q3 2009 Q4 2009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011

Col

orec

tal S

SI ra

teSSI Rate and Interventions

Quarter 3Skin preparation protocolPre-op wash clothes

Quarter 4CUSP kickoffAntibiotic deficiencies addressed

Quarter1Pre-op warmingEnhanced sterile techniqueIntervention checklist

42 %

17 %

29 %26 %

16 %20 % 19 % 18 %

HIGHLIGHTS FROM YEAR 2EXPANDING THE SCOPE

Armstrong Institute for Patient Safety and Quality19

Building Capacity:Armstrong Institute Patient Safety Fellowship

Tracie Cometa, RN Kevin Driscoll, CRNA

• 16 hrs per week (Jan-June 2012)• 8 hrs classroom training on patient safety• 8 hrs protected time for quality improvement projects

8/7/201220

Briefing and Debriefing

• Team developed new form based on needs

• RN given protected time to address concerns raised during briefing and debriefing

• Candid discussion with surgeons about effective strategies for briefing/debriefing

• Ongoing observations of briefing to address defects

Standardization of perioperative steroid use

Lucy Mitchell RN,MSN, SCR– Noted 50% SSI rate in patients on steroids

• Pharmacy led audit of perioperative steroid use demonstrated 50-200mg hydrocortisone administered intra-op

Raymon Lamore Pharm D.

Engaging Other Providers: Peer Outcome Reports

Armstrong Institute for Patient Safety and Quality23

• Provider specific data compared to peers• All surgeons performing > 10 colorectal procedures per year• Sets the stage that problem is preventable and a social problem

Surgeon ID

ACS NSQIP (defined

variables) 30-Day Mortality

Rate

Superficial Incisional

SSI

Deep Incisional

SSIOrgan/Space

SSIWound

DisruptionPulmonary Embolism

Urinary Tract Infection

Transfusion Intraop/ Postop Sepsis

Septic Shock

1

2

3

Dr. Wick

5

6

7

8

Site Total 9 2.3% 61 15.4% 2 0.5% 21 5.3% 5 1.3% 10 2.5% 20 5.0% 69 17.4% 13 3.3% 9 2.3%

Comparison480 3.3% 1,049 7.2% 206 1.4% 649 4.5% 206 1.4% 130 0.9% 572 3.9% 2,448 16.8% 755 5.2% 384 2.6%

TARGETED PROCEDURE MODULE

Lessons Learned

• Harm is preventable

• Change can not be “top down”

• CUSP sends a clear message, all provider opinions and ideas are important and essential for improvement

• Better teamwork better outcomes better culture and teamwork

• Positive culture empowers frontline staff to take ownership of patient safety and achieve unprecedented improvements

• It takes time and commitment

Johns Hopkins Hospital Motto

Our experience: hospital level interventions(SCIP) pale in comparison to interventions at the work unit level (CUSP)

We embrace local wisdom in the Colorectal OR’s

25© JHU and JHHS, 2009