THIS PRESENTATION/PUBLICATION/ OR OTHER PRODUCT IS DERIVED FROM WORK SUPPORTED UNDER A CONTRACT WITH THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) (Contract No. HHSA290200600022, TASK ORDER # 7).  HOWEVER, THIS PRESENTATION/PUBLICATION/OR OTHER PRODUCT HAS NOT BEEN APPROVED BY THE AGENCY.

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CUSP ToolsName of CUSP Tool Purpose

Science of Safety Training Attendance Sheet

Verify participation in screenings of the “Understand the Science of Safety” educational video

Staff Safety Assessment

Inventory threats to patient safety that frontline care providers identify

Background Quality Improvement Form (Team List)

Gather names, titles, and contact information for unit safety improvement team

Learning From Defects Set up a process to learn from and respond to defects within the unit

Case Summary Form Analyze a case example of patient harm or a near-miss to identify system factors and opportunities for improvement

Daily Goals Checklist Improve team communication regarding the patient’s plan of care

More CUSP ToolsName of CUSP

ToolPurpose

Morning Briefing Get everyone on the same page at the beginning of a day or shift to set expectations and make the day more predictable

Shadowing Another Professional

Identify and improve communication, collaboration, and teamwork skills among different practice domains

Safety Issues in the Executive Partnership

Identify safety issues and recommendations for improvement identified by frontline staff in conversation with a senior executive.

Status of Safety Issues

Track previously identified safety issues and recommendations for improvement and status of improvement efforts

Culture Debriefing Tool

Provide a structured process to make culture results actionable 5

Learning Objectives

Determine next steps for your team

Review and understand the key steps of the CUSP Toolkit

Review key CUSP tools

Learn how Just Culture principles can augment CUSP

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CUSP Toolkit Modules

Introduce CUSP

Assemble the Team

Engage the Senior Executive

Understand the Science of Safety

Identify Defects Through Sensemaking

Implement Teamwork and Communication

Apply CUSP

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Video

(10-minute Conclusion video)

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Assemble the Team

Understand the importance of your CUSP team

Develop a strategy to build a successful team

Define roles and responsibilities of team members

Identify characteristics of successful teams and barriers to team performance

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Keys to Assembling the Team

Remember that culture is local

Include engaged frontline providers who take ownership of patient safety

Select team members with different levels of experience

Include team members based on clinical intervention

Hold regular meetings (weekly or monthly), set action items, and create meeting agendas

Encourage input from all team members

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Assemble the Team: What the Team Needs to Do

Recruit a team lead, nurse manager, physician, and executive partner along with any other team members

Meet with hospital departments (risk management, quality improvement, infection prevention) to ensure that CUSP efforts are integrated into overall hospital quality improvement and patient safety efforts.

List team member names and contact information on the Background Quality Improvement Form and post the form in a central location

Leverage the 4Es to ensure team engagement:

1. Engage them in the process

2. Educate them about their roles

3. Execute the processes

4. Evaluate what you did

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Engage the Senior Executive

Identify the main characteristics and responsibilities of the Senior Executive

Understand the role of the Senior Executive in addressing technical and adaptive work

Learn how to engage and hold your Senior Executive accountable

Apply tactics used by leaders to engage the Senior Executive

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Keys to Engaging the Senior Executive

Show how CUSP supports and leverages other improvement projects

Illustrate how CUSP will increase the senior executive’s visibility

Ensure that a senior executive is assigned to and meets regularly with the CUSP team

Identify safety issues in the Safety Issues Worksheet for Senior Executive Partnership or a tracking log

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Engage the Senior Executive: What the Team Needs to Do

The CUSP team leader or members of the safety team should meet with the senior executive before the executive holds safety rounds to share unit-specific information• In preparation, gather relevant information about the unit for the

senior executive

During executive safety rounds, the patient safety team, senior executive, and unit providers should review any safety issues identified, particularly those related to CAUTI, and list them on a tracking log• In preparation for executive safety rounds, the unit champion

should: Brief providers on the purpose of partnering with a senior

executive Ask them to be prepared to discuss their own safety concerns and

suggestions for resolution during rounds

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Understand the Science of Safety

Recognize the historical and contemporary context of the science of safety

System design affects system results

List the principles of safe design

Safe design principles apply to technical and team work

Teams make wise decisions when there is diverse and independent input

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Keys to Understanding the Science of Safety

Develop a plan to have all staff on your unit view the Understand the Science of Safety video

Make watching the video mandatory for all unit staff

Create a list of who has watched the video

Describe the three principles of safe design:

1. Standardize

2. Create independent checks

3. Learn from defects

Identify Defects Through Sensemaking

Introduce tools that will help teams identify defects

Introduce Sensemaking: • A process of assigning meaning to ambiguous

events or data

Show teams how to identify defects

Show how Sensemaking relates to Learning from Defects

Answer each of the four questions from the Learning from Defects Tool

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Keys to Identifying Defects Through Sensemaking

A defect is anything that you do not want to happen again

The team should use the Learning from Defects Tool, which asks teams to answer these four questions:

1. What happened?

2. Why did it happen?

3. What will you do to reduce the risk of recurrence?

4. How do you know it worked?

The team should:• Share summaries of defects within your organization • Engage staff in conversations to enhance Learning from Defects

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Identify Defects Through Sensemaking: What the Team Needs to Do

The CUSP team leader, or another designee, should distribute the Staff Safety Assessment to all clinical and non-clinical providers on the unit.

Safety assessments should be:

Grouped by common types of defects

Prioritized based on the following criteria: • Likelihood of harming the patient• Severity of harm• Commonality• Likelihood that it can be defended against in daily work

Shared with the senior executive

Implement Teamwork and Communication

Recognize the importance of effective communication

Notice the barriers to communication

Discover any connections between communication and medical error

Identify and apply effective communication strategies from CUSP and TeamSTEPPS

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The Keys to Effective Communication

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Implement Teamwork and Communication:

What the Team Needs to Do

Identify opportunities to improve teamwork and communication by reviewing barriers the team identified while learning from a safety defect

Discuss with frontline providers how and where they want to improve communication

Select a tool that best addresses providers’ concerns

Use teamwork and communication tools and incorporate them into team meetings and other relevant project processes

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CUSP and TeamSTEPPS Communication Strategies

Daily Goals Checklist

Briefing and Debriefing

Shadowing another professional

Handoff

I PASS the BATON

Check-back

Call out

Completing the Staff Safety Assessment

Step 1. Identify clinical or operational problems that threaten patient safetyStep 1. Identify clinical or operational problems that threaten patient safety

Step 2. Identify ways in which patients on the unit might be harmedStep 2. Identify ways in which patients on the unit might be harmed

Step 3. Determine what can be done to minimize harm or prevent safety hazardsStep 3. Determine what can be done to minimize harm or prevent safety hazards

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Using the Safety Issues Worksheet for Senior Executive Partnership

1. Engage the senior executive to address safety issues identified in the form

2. Use the worksheet during safety rounds to identify safety issues, potential solutions, and available resources

3. Keep the project leader apprised of the information on the worksheet

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Learning from Defects

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Using Daily Goals

During morning and evening rounds, the care team should use the checklist to review the goals for the patient

Once a checklist is completed, the attending signs it and gives it to the patient’s nurse to keep it at the bedside, and the team moves on to the next patient

The Daily Goals Checklist should be tailored to fit your environment

Applying Just Culture Principles

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Video

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Just Culture

A system that –o Holds itself accountableo Hold staff members accountableo Has staff members that hold

themselves accountable

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Understanding Risk andHuman Behavior

Human ErrorHuman Error: : Inadvertently doing Inadvertently doing

other than what other than what should have been should have been done; slip, lapse, done; slip, lapse,

mistakemistake

Human ErrorHuman Error: : Inadvertently doing Inadvertently doing

other than what other than what should have been should have been done; slip, lapse, done; slip, lapse,

mistakemistake

At-Risk BehaviorAt-Risk Behavior: : Choosing to behave Choosing to behave

in a way that in a way that increases risk where increases risk where

risk is not risk is not recognized or is recognized or is

mistakenly believed mistakenly believed to be justifiedto be justified

At-Risk BehaviorAt-Risk Behavior: : Choosing to behave Choosing to behave

in a way that in a way that increases risk where increases risk where

risk is not risk is not recognized or is recognized or is

mistakenly believed mistakenly believed to be justifiedto be justified

Reckless BehaviorReckless Behavior: : Choosing to Choosing to consciously consciously disregard a disregard a

substantial and substantial and unjustifiable riskunjustifiable risk

Reckless BehaviorReckless Behavior: : Choosing to Choosing to consciously consciously disregard a disregard a

substantial and substantial and unjustifiable riskunjustifiable risk

Managing Error and Risk

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Human Error

Product of Our Current System

Design and Behavioral Choices

Manage through changes in:•Choices•Processes•Procedures•Training•Design•Environment

Console

At-Risk Behavior

A Choice: Risk Believed Insignificant

or Justified

Manage through:•Removal of incentives for at-risk behaviors•Creation of incentives for healthy behaviors•Situational awareness

Coach

Reckless Behavior

Conscious Disregard of Substantial and Unjustifiable Risk

Manage through:•Remedial action•Punitive action

Punish

Systems and BehaviorsWork Together to

Improve Outcomes

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Mission, Values Mission, Values and Expectationsand Expectations

SystemSystemDesignDesign

BehavioralBehavioralChoicesChoices

Improved Improved OutcomesOutcomes

LearningLearningSystemsSystemsLearningLearningSystemsSystems

AccountabilityAccountabilityand Justiceand Justice

AccountabilityAccountabilityand Justiceand Justice

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Engineering System Design to Support Behavior Choices

Punitive Culture: Transparency is impossible

Blame-Free Culture: No accountability

Just Culture: Optimally supports a system of safety

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Leadership Team’s Role inApplying Just Culture Principles

Have a procedure in place for employees to follow

Ensure employees are properly trained

Offer positive reinforcement at the monthly Learning from Defects meeting

Video

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Video

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Team Members’ Role inApplying Just Culture Principles

Lisa noticed that several of her patients had catheters left in place that, per the protocol, should have been removed during the prior shift

Lisa used Just Culture principles to review the situation

Summary

The seven CUSP Toolkit modules:o Introduce CUSPo Assemble the Teamo Engage the Senior Executiveo Understand the Science of Safetyo Identify Defects through Sensemakingo Implement Teamwork and Communicationo Apply CUSPWhen implementing CUSP for the first time, it is recommended to use the modules in this order.

o For subsequent implementations, use the modules based on the unit’s needsUse the Just Culture principles in tandem with the CUSP principles

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References

Agency for Healthcare Research and Quality. TeamSTEPPS Fundamentals Course: Module 6 Communication. Available at: http://teamstepps.ahrq.gov/abouttoolsmaterials.htm Accessed August 18, 2011.

Agency for Healthcare Research and Quality. Sensemaking. Available online at: http://dkv.columbia.edu/demo/medical_errors_reporting/site/module3/0100-module-outline.html. Accessed August 18, 2011.

Dayton E, Henricksen K. Communication failure: basic components, contributing factors and the call for structure. Joint Commission Journal. 2007;33(1):36.