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CUSP: A Framework for


Working Together – The Players

• Centers for Medicare & Medicaid Services Quality Improvement

Organization (CMS QIO)
• Agency for Health Care Research and Quality (AHRQ)
• On the CUSP: Stop HAI
• CLABSI National Project Team
– Michigan Health & Hospital Association - Michigan Keystone
Center for Patient Safety & Quality (MHA Keystone)
– Armstrong Institute for Patient Safety and Quality Johns
Hopkins University (JHU)
– Health Research & Educational Trust (HRET), research affiliate
of the American Hospital Association

Learning Objectives

• Understand CUSP impact on safety

• List CUSP components
• Describe how a hospital implemented

ICU Safety Climate
Effect of CUSP on Safety Climate

% "Needs Improvement" *

50 47

Pre vs. Post Intervention

Pre-CUSP (2004) Post-CUSP (2006)

* “Needs Improvement” - Safety

4 Climate Score <60%
Culture / Climate and Outcomes

No BSI = 5 months or more w/ zero

The strongest predictor of clinical

excellence: Caregivers feel
comfortable speaking up if they
perceive a problem with patient care

No BSI 21% No BSI 31% No BSI 44%

Attribution: J. Bryan Sexton
Teamwork Climate &
Annual Nurse Turnover
% reporting positive teamwork climate

20 High Turnover 16.0% Mid Turnover 10.8% Low Turnover 7.9%

RN Teamwork Climate Staff Physician Teamwork Climate

Ideas for Ensuring Patients Receive
the Interventions: the 4Es
• Engage: Stories, show baseline data

• Educate staff on evidence

• Execute
– Standardize: Create line cart
– Create independent checks: Create BSI checklist
– Empower nurses to stop takeoff
– Learn from mistakes

• Evaluate
– Feedback performance
– View infections as defects
Ensure Patients Reliably Receive
Senior Team
leaders leaders
Engage How does this make the world a better place?
Educate What do we need to do?
What keeps me from doing it?
How can we do it with my resources and culture?

Evaluate How do we know we improved safety?

Pronovost: Health Services Research, 2006
Have We Created a Safe Culture? How Often Do We Harm?
How Do We Know We Learn Are Patient Outcomes
From Mistakes? Improving?

Comprehensive Unit-based Safety (TRiP)
Program Translating Evidence Into Practice

1. Educate staff on science of 1. Summarize the evidence in a checklist

safety 2. Identify local barriers to
2. Identify defects implementation
3. Assign executive to adopt unit 3. Measure performance
4. Learn from one defect per 4. Ensure all patients get the evidence
5. Implement teamwork tools

9 Improve
What is CUSP?

• Comprehensive Unit-based Safety Program

• An intervention to learn from mistakes and improve safety


On the CUSP: Stop BSI

Comprehensive Unit-based BSI-Reduction Protocol

Safety Program (CUSP)
-Best-evidence supplies,
-Improve or reinforce good cross-
organization of supplies
disciplinary communication and
teamwork -Ensuring all patients receive the
best practices
-Enhance coordination of care
-Checklist to ensure consistent
-Address overall patient safety
application of evidence
-Work towards healthy unit culture
Pronovost, Berenholtz, Needham BMJ 2008
Safety Score Card
Keystone ICU Safety Dashboard
2004 2006
How often did we harm (BSI)? (median) 2.8/1000 0
How often do we do what we should? 66% 95%
How often did we learn from mistakes?* 100s 100s
Have we created a safe culture?
What areas need improvement?
Safety climate* 84% 43%
Teamwork climate* 82% 42%

* CUSP is intervention to improve these

Pre CUSP Work

• Create a CUSP team

– Nurses, physician, support staff, infection preventionist
– Assign a team leader
• Measure culture in the unit
• Work with hospital quality leader or hospital
management to have a senior executive assigned to
CUSP team

Steps of 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

Pronovost J, Patient Safety, 2005
Step 1: Science of Safety
• Understand system determines performance

• Use strategies to improve system performance

– Standardize
– Create independent checks for key process
– Learn from mistakes

• Apply strategies to both technical work and teamwork

• Recognize teams make wise decisions with diverse and

independent input

Step 2: Identify Defects

• Administer the staff safety assessment and ask staff,

“How will the next patient be harmed?”
• Review error reports, liability claims, sentinel events,
or M and M conference

Prioritize Defects

• List all defects

• Discuss with staff what are the three greatest risks and
what you should work on first

Step 3: Executive Partnership

• Executive should become a member of unit team

• Executive should meet monthly with unit team
• Executive should –
– Review defects
– Ensure unit team has resources to reduce risks
– Hold team accountable for improving risks and central line-
associated blood steam infection rate

Step 4: Learning from Mistakes

• What happened?
• Why did it happen (system lenses)?
• What could you do to reduce risk?
• How do you know risk was reduced ?
– Create policy, process, or procedure
– Ensure staff know policy
– Evaluate if policy is used correctly

Pronovost 2005 JCJQI
Step 4 cont’d: Identify Most Important
Contributing Factors
• Rate each contributing factor

– Importance of the problem and contributing factors

• In causing the accident
• In future accidents

Step 4 cont’d: Identify Most
Effective Interventions

• Rate each intervention

– How well the intervention solves the problem or
mitigates the contributing factors for the accident
– Rate the team belief that the intervention will be
implemented and executed as intended

Step 4 cont’d: Evaluate Whether Risks
Were Reduced

• Did you create a policy or procedure

• Do staff know about the policy
• Are staff using it as intended
• Do staff believe risks have been reduced

Step 5: Teamwork Tools

• Call list
• Daily goals
• Morning briefing
• Shadowing
• Culture check up

Pronovost JCC, JCJQI
Step 5 cont’d: Call List

• Ensure your unit has a process to identify which

physician to page or call for each patient
• Make sure call list is easily accessible and updated

Step 5 cont’d: Morning Briefing

• Have a morning meeting with charge nurse and unit

attending(s) about the unit-level plan for the day
• Discuss work for the day
– What happened during the evening
– Who is being admitted and discharged today
– What are potential risks during the day; how can we reduce these risks

Step 5 cont’d: Shadowing

• Follow another type of clinician doing his or her job for

between 2 and 4 hours
• Have the shadower discuss with staff what he or she will do
differently now that he or she has walked in another
person’s shoes

CUSP is a Continuous Effort

• Add science of safety education to orientation

• Learn from one defect per quarter; share or post lessons
• Implement teamwork tools that best meet the unit’s needs
• Review details in the CUSP manual

Action Items -- CUSP

• Look over the CUSP manual with team members

• Brainstorm potential hazards with team
• Assess team composition with respect to CUSP elements
• Review pre-implementation checklist — where are you?


• Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a

comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40.

• Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU

using daily goals. J Crit Care. 2003; 18(2):71-75.

• Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A

model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68.

• Thompson DA, Holzmueller CG, Cafeo CL, et al. A morning briefing: Setting the
stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005;