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

Armstrong Institute for Patient Safety and Quality

CUSP for Safe Surgery: The Surgical Unit-Based Safety Program

Project Overview

Learning Objectives

• Understand the magnitude of preventable harm

• Identify SUSP program– Project goals and interventions

– Participation requirements and timeline

• Describe steps to enroll in SUSP

The Problem is Large

• In U.S. Healthcare system

– 7% of patients suffer a medication error 2

– On average, every patient admitted to ICU suffers adverse event 3,4

– 44,000- 98,000 people die in hospitals each year as the result of

medical errors 5

– Nearly 100,000 deaths from HAIs 6

– Estimated 30,000 to 62,000 deaths from CLABSIs 7

– Cost of HAIs is $28-33 billion 7

• 8 countries report similar findings to the U.S.

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2. Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995

3. Donchin Y, Gopher D, et al., Crit Care Med, 1995.

4. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997.

5. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999.6. Klevens M, Edwards J, Richards C, et al., PHR, 20077. Ending Health Care-Associated Infections, AHRQ, 2009.

Preventable HarmPreventable Harm

• 230 million surgeries / yr worldwide– More common than births ( 36 million / yr) – 1 in 25 people

• 25% in-patient surgeries followed by complication– 7 million disabling complications / yr

• 0.5 – 5% deaths following surgery– 1 million deaths / yr

• 50% of all hospital adverse events linked to surgery– At least 50% of adverse surgical events are

avoidable

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

Surgical Care Improvement Project (SCIP)

CMS National Impact Assessment of Medicare Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NationalImpactAssessmentofQualityMeasuresFINAL.PDF. March 2012; 42.

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

SUSP Project Overview

SUSP Project Overview

• AHRQ funding project– Individual hospitals participate for 2 years

• Leveraging leaders in field – Armstrong Institute, ACS NSQIP, AHRQ, University

of Pennsylvania, WHO

• All hospitals in any state, as well as hospitals in the District of Columbia and Puerto Rico are encouraged to participate.

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SUSP Enrollment(as of Nov 2012)

• Cohort 1 (July 2012)– 11 hospitals

– 3 Coordinating Entities (FL, CO, TN) & University of Washington

• Cohort 2 (started Sept 2012)– 104 hospitals

– 11 Coordinating Entities (AR, CO, CT, FL, HI, IO, MI, NSN, NV, AI, TN)

– Cohort 3: will start Feb 2013

• Cohort 4: TBDArmstrong Institute for Patient Safety and Quality

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Project Goals

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

• To achieve significant improvements in safety culture

How will we get there?

Comprehensive Unit based Safety

Program (CUSP)

1. Educate staff on science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

Translating Evidence Into

Practice(TRiP)

1. Summarize the evidence

2. Identify local barriers to implementation

3. Measure performance

4. Ensure all patients get the evidence

• Engage• Educate• Execute• Evaluate

Reducing Surgical Site Infections

• Emerging Evidence

• Local Opportunities to Improve

• Collaborative learning

http://www.hopkinsmedicine.org/armstrong_institute

Technical Work Adaptive Work

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 4

1. N Engl J Med 2006;355:2725-32.

2. BMJ 2010;340:c309.

3. Infect Control Hosp Epidemiol. 2011;32(4): 305-314.

4. www.onthecuspstophai.org

Percent of Units with Zero CLABSIs and Achieving Project Goal (<1/1000 CL days)

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*Data drawn from Interim Project Report – Figure 5 – Cohorts 1 through 3

www.onthecuspstophai.org

Advancing the ScienceAdvancing the Science

• Harm is preventable– Many healthcare acquired infection and complications are

preventable; should be viewed as defect

• Technical and adaptive work – Focus on systems; Not individuals– Engaging frontline staff to identify and fix local opportunities to

improve

• Framing as social problem that can be solved– Clinical communities

Wrong-patient, Wrong-site, Wrong-procedure Events Reviewed by The Joint Commission

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

How is SUSP different?

• Informed by science

• Led by clinicians and supported by management

• Guided by measures

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

SUSP Interventions

SUSP Interventions

•  No single SSI prevention bundle– Deeper dive into SCIP measures to identify

local defects

– Emerging evidence• Bowel Prep• Antibiotic redosing• Alcohol based skin prep 

• Capitalize on frontline wisdom to identify local opportunities to improve – CUSP/Staff Safety Assessment

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Comprehensive Unit-based Safety Program (CUSP)

1. Educate staff on science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

Jt Comm J Qual Patient Saf 2010;36:252-60 Resources: http://www.ahrq.gov/cusptoolkit/

SUSP Interventions

• Implement WHO briefings / debriefings– Growing body of evidence to support use– Adapt to local environment

• Tools focused on SSI Prevention– SSI Investigation, Skin Prep Audit, – Antibiotic Audit, Normothermia Audit and others

• Additional interventions will be provided that teams may choose to implement, including but not limited to activities to reduce mislabeled specimens, wrong sided surgery, and retained foreign objects

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Potential benefits

• National effort led by clinicians – Shared learning

– We will learn from each other

• Advancing science together – Building relationships in surgical community that will

last beyond the project

– Cutting edges tools and resources including ethnographic studies and platform that links data collection, reporting, and training with social networking to improve communication and sharing

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

What do teams need to do?

– Assemble a multidisciplinary team• Including Preop, OR and Postop staff

– Participate in 6 weekly on-boarding webinars– Participate on monthly content webinars– Participate on monthly coaching webinars

• All webinars recorded and archived online

– Participate in annual face-to-face meetings– Regularly meet as a team to implement

interventions and monitor performance

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What data will teams need to collect?*

• Monthly SSI data for colorectal and general surgery patients– Numerator and denominator

• Quarterly project implementation data – Structured interview and brief survey

• Annual teamwork/culture data using the AHRQ Hospital Survey of Patient Safety (HSOPS)

• Other complications from ACS NSQIP as program evolves 

• Will work with HENS to ensure data reporting meets their needs

*If data is already collected/available (ie: ACS NSQIP or NHSN), we will work with your team to import if you desire

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Timeline

• Months 1-3: Planning and preparation– Participate in Immersion calls*– Identify CUSP team members (OR with representation from PACU and

Floor) including executive leadership– Administer culture survey to all perioperative staff (OR, PACU, Floor)

• Initial Roll Out: Months 4-6 – Educate on science of safety– Conduct staff safety assessment (OR, PACU, Floor focus)– Conduct culture checkup

• Feedback and benchmarking results of HSOPS survey

– Initiate SSI Prevention Activities: Explore opportunities to ‘deep dive’ into SCIP measures and emerging SSI prevention interventions.

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• Months 7- 9 – Implement Learning from Defects Tool I

– Implement briefings, building on WHO checklist to address defects

– Continue SSI Prevention Activities

– Optional tools including Investigating an Infection Tool, Skin Prep Audit Tool, SSI prevention activity audits, teamwork tools (based in TeamSTEPPS) and patient education related tools

• Months 10-12– Implement debriefings, building on WHO checklist as tool to address

defects (OR activity)

– Continue SSI Prevention Activities and expand to new topics.

– Optional tools including Handoff Tools, Shadowing tool, teamwork assessment & learning from a communication failure

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Timeline

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Timeline

• Months 13-24– This project will continue for an additional 6 to 12

months after the end of Year 1. – Expand efforts

• To improve technical work (e.g., DVT/PE, Wrong sided surgery, retained foreign objects

• To Improve teamwork, communication, and culture (e.g., additional aspects of teamwork training)

Challenges

• Engaging frontline staff– Staff time (2-4 hr/week for each RN, surgeon,

anesthesia, team leader, infection preventionist)

• CUSP executive partnership • Data collection burden • Often no forum for joint learning • Need to learn together

– Many examples of success

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JHU Colorectal CUSP

• Standardization of skin preparation

• Preoperative chlorhexidine showers

• Selective elimination of mechanical bowel preparation

• Warming of patients in the pre anesthesia area

• Enhanced sterile techniques for bowel and skin portions of the case

• Addressing lapses in prophylactic antibiotics J Am Coll Surg 2012;215(2):193-200.

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JHU Colorectal CUSP

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*p<0.05 J Am Coll Surg 2012;215(2):193-200.

On-boarding Call Evaluation

We want to ensure that the on-boarding calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link:

•https://www.research.net/s/susp_cohort_3

If you are not able to reach the link from the slide, please cut & past the URL into your browser.

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