Comprehensive Unit-based Safety Program(CUSP)

Teré Dickson, MD, MPHHAI Webinar April 9, 2012

CMS Leads a national healthcare quality improvement program,

implemented locally by an independent network of QIOs in each state and territory.

IPRO The federally funded Medicare Quality Improvement

Organization (QIO) for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS).

2

The QIO Program Largest federal program dedicated to improving health

quality at the local level,

Trustworthy partners for the continual improvement of healthcare for all Americans,

Focuses on three broad aims:

Better patient care,

Better population health,

Lower healthcare costs through improvement.

3

As the QIO for New York State, IPRO works to achieve the goals of the national QIO program by Convening communities of providers, practitioners and

patients across the state to:

Share knowledge,

Spread best practices,

Achieve rapid, wide-scale improvements in patient care.

4

The QIO Program supports patients by: Providing information to help you better manage your

own healthcare,

Reviewing quality of care complaints,

Working with local healthcare providers to make healthcare safer and “patient-centered,”

Listening to you and learning from your experiences,

Helping to remove roadblocks between you and better healthcare.

5

The QIO Program supports providers by: Managing and sharing evidence-based best practices,

knowledge and tools for improving health quality, efficiency and value.

Serving as a change agent for rapid, widespread and significant improvements that contribute to broader national healthcare goals.

Facilitating collaborative learning and action that results in better, more patient-centered care.

Encouraging beneficiaries to take a more active role in their own healthcare.

6

QIO Program Priorities 2011-2014

Beneficiary- and Family-Centered Care

Improving Individual Patient Care by Reducing Healthcare-Associated Infections in Hospitals

Healthcare-Acquired Conditions in Nursing Homes

Adverse Drug Event

and through Quality Reporting

Integrating Care for Populations and Communities

Improving Health for Populations and Communities

7

Today’s Webinar:CUSP Town Hall Meeting

A town hall meeting is an informal public meeting which gives the members of a community an opportunity to get together to discuss emerging issues and to voice concerns and preferences for their community.

- www.wisegeek.com

8

Interact with us!

Operator assisted call

Chat box To the group

To the moderator

When you respond or comment, please say your name and hospital.

9

Special Guests – St. John’s Episcopal Hospital

St. John’s Episcopal Hospital is the only full service community hospital serving the entire Rockaway and the Five Towns communities providing general adult medical surgical services, pediatrics, obstetrics and psychiatric services. Initiated CUSP in January 2010

Gail Johnson

Nancy Traver

10

Poll Question 1

My hospital has started using CUSP to address CLABSIs and CAUTIs. Yes

No

11

Poll Question 2

My hospital has considered using CUSP, but either decided against it or doesn’t know how to get started. Yes

No

12

Poll Question 3

My hospital has an alternative to CUSP in place, such as the use of brainstorming teams, multidisciplinary patient safety rounds with hospital administration, feedback to unit staff on infection rates and targets, educational sessions for unit staff, and/or application of root cause analysis to investigate infections. Yes

No

13

Principles of CUSP

Understand system determines performance and results.

Use strategies to improve system performance.

Apply strategies to both technical work and team work.

Recognize teams make wise decisions with diverse and independent input.

14

Five Steps of CUSP

1. Educate staff on the science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

15

The 4E’s to CUSP Success

Engage Storytelling, Press releases, Share data

Educate staff on evidence

Execute Standardize

Create independent checks

Empower nursing

Learn from mistakes

Evaluate Performance and progress feedback

16

Keep It Simple

CUSP Learn from 1 defect per desired time period Collaboration Consolidation Sustainability

17

CUSP In-depth

On The CUSP: Stop HAIhttp://www.onthecuspstophai.org/

18

The St. John’s Episcopal Hospital CUSP Experience

19

Choosing CUSP

Driving Forces High CLABSI Rate

MICU: 2.6/1000 device days in 2010 with a national mean of 1.9

Hospital Administrator - Sharon Behar, VP for Regulatory Affairs

HANYS and national On the CUSP initiative

20

Pre-CUSP Activities

Web Conferences

Team Formation Administrative Champion

Infection Control Committee Chairman

Physician Champion

Nursing Champion (VP of Patient Care Services)

Infection Preventionist

Data Collection

AHRQ Hospital Survey on Patient Safety

Trained staff on Science of Safety

21

CUSP Processes for CLABSI Prevention

Removal of the defects that lead to central line related bacteremia

Understanding the complexity involved to creating a plan to reduce errors

Putting all equipment needed for insertion in one place and/or pkg

Residents must notify nurse who will assist with insertion Insertion checklist to empower nurses to document

deviations Observing Rounds AM and PM Briefing Daily Goals Checklist

22

CUSP Intervention - Peer Review

Developed the peer review form to assess the compliance with all strategies and bundles. The night shift monitors

the day shift on care for patients with lines and vice versa.

23

CUSP Results

MICU had a rate of 2.6/1000 device days in 2010 with a national mean of 1.9 2011: the rate had dropped to 1.5 below the national mean

of 1.6

Feedback to Staff CUSP Boards where infection rates were posted monthly

Fun Competition

 

24

CUSP Sustainability and Expansion

After about 6 months, noticed modest gains in monthly rate reduction Decided to host more CUSP trainings with video about

Josey King

At 9 months – CUSP went housewide! (Med Surg and Pulmonary floors)

Recruited different physician champions and unit/floor champions with same administrative champion

Champions brought others on board with roll-out and were instrumental in CUSP success

25

Townhall Discussion

Data resources used Education tactics – Science of Safety and CUSP

directed initiatives Engagement tactics – Executive and front line staff Team member selection and team building Scheduling concerns – consolidate with other

meetings vs separate timing Investigations of defects Feedback methods Sustainability

26

Townhall Discussion

What is your hospital doing as an alternative to CUSP?

27

Feedback on CUSP Trainings and Resources

Fall LAN Meeting

AHRQ/HRET National Webinar on CUSP

http://hai.ipro.org

Quarterly Newsletters – CUSP Corner

Today’s Webinar/Townhall

28

This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM7.1-12-04

For more information

Teré Dickson, MD, MPHMedical Officer(516) 209-5324tdickson@nyqio.sdps.org

IPRO CORPORATE HEADQUARTERS

1979 Marcus AvenueLake Success, NY 11042-1002

IPRO REGIONAL OFFICE

20 Corporate Woods BoulevardAlbany, NY 12211-2370

www.ipro.org

Template 1/13/2012