Document 1
The Basics of CUSP
Coaching Call 2:
Staff Safety Assessment and
Measuring Culture
10/19/2010
Pat Posa RN, BSN, MSA
System Performance Improvement Leader
St. Joseph Mercy Health System
Ann Arbor, MI
[email protected]
Kimberly O’Brien, MHA
Project Manager
Missouri Center for Patient Safety
Jefferson City, MO
[email protected]
Before We Get Started . . . A Few
Housekeeping Items
• Post-coaching call surveys
– Team leader will receive by email following each coaching call
– Team leader must complete each one
• Science of Safety DVDs
– Have you received your copy?
– If no, contact Kimberly: [email protected]
• Supplemental call for late-comers
– Wednesday, November 3rd, 12:00-1:00pm
– Overview of CUSP, the structure of this module, and plenty of Q&A time
– Link to audio file recording will be provided following the call, but we
encourage live participation
• Team leaders should attend coaching calls
2
Before We Get Started . . . A Brief
Recap of Coaching Call 1 (9/21/10)
• Overview of CUSP (6 steps)
• Structure of this training program
– 6 coaching calls
– Each coaching call will cover 1 or 2 steps of CUSP
– Team leaders will have homework after each call to implement each step
• Coaching Call 1 Team Lead Checklist
–
–
–
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Choose a unit to implement CUSP
Recruit a CUSP team and executive sponsor
Schedule CUSP team meetings for 6 months or more
Team leads and team members listen to/view the Physician Engagement and
Science of Safety videos
• DVDs mailed to each team lead
– Facilitate first team meeting (for teams that are established)
– Complete post-coaching call survey
3
The “Secret Ingredient”
Comprehensive Unit-Based Patient
Safety Program
1. Form a unit CUSP team with executive
sponsorship
2. Measure unit culture
3. Educate staff on Science of Safety
4. Identify defects using the Staff Safety
Assessment; prioritize defects
5. Learn from one defect per quarter
6. Implement team/communication tools
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Step 3:
Educating Staff on the Science
of Safety
5
Review from Session 1:
Understanding the Science of Safety
• How can errors happen?
– People are fallible
– Medicine is still treated as an art, not science
– Need to view the delivery of healthcare as a
science
– Need systems that catch mistakes before they
reach the patient
6
Review from Session 1:
Understanding the Science of Safety
• How can we improve?
– Every system is perfectly designed to achieve the results it
gets
– Understand principles of safe design
• standardize, create checklists, learn when things go wrong
– Recognize these principles apply to technical and team
work
– Teams make wise decisions when there is diverse and
independent input
Caregivers are not to blame
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Methods to Educate on Science of
Safety
• Content:
– Josie King DVD or share own hospital story
– “Science of Safety” video by Peter Pronovost, MD from
Johns Hopkins University
– We will provide you with three presentations that you can
select slides from or use as is
• Have the CUSP team make final decision on content
– Couple team members put it together and present to CUSP
team
– CUSP team provides input and decides on final product
that will be used to educate all staff
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Key Messages to Include
• Safety is everyone’s responsibility
• Mistakes are usually the result of system and
process issues—improving those will improve
safety
• Improving culture will positively impact safety
• Remember the human factor—we all make
mistakes---our job is to identify risks and put
in place processes to mitigate that risk
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Strategies to Educate on Science of
Safety
• Delivery Strategies
– 30minutes in length
– Mandatory for all staff
– Provided on all shifts to all providers
– Reminders and reinforcement in daily huddles
• Consider having staff complete the Staff Safety Assessment at
the end of the education session
– Place completed assessment in envelope or box
• Track Attendance
• Discuss how to educate new staff on science of safety
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Step 4:
Staff Safety Assessment:
Identifying Defects
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Staff Safety Assessment
• What is it?
• Why is it important?
• What is the CUSP team going to do with the
information?
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Staff Safety Assessment
What is it?
• Two questions for bedside staff:
– Please describe how you think the next patient in
your unit/clinical area will be harmed
– Please describe what you think can be done to
prevent or minimize this harm
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Staff Safety Assessment
Why is this Important?
• Frontline staff are the best people to identify
safety issues
• By asking them what the issues are,
responding to their issues, and including their
wisdom to develop solutions they become a
part of improving safety on the unit
• Staff will begin to understand their role and
responsibility in the safety on the unit
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Staff Safety Assessment
What is the CUSP team going to do with this data?
• Collate the data
• Identify issues/themes
• Prioritize an issue/defect to resolve using the
Learn from a Defect Tool
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Timeline for Science of Safety Staff
Education and Staff Safety Assessment
• 10-20 to 11-1:
Plan content and set up
in-service schedule for Science
of Safety Education and Staff
Safety Assessment
• 11-1 to 11-16:
Conduct in-services and
administer Staff Safety
Assessment questionnaire
• 11-16 to 11-22:
Collate results of Staff
Safety Assessment
questionnaire
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Step 2:
Measuring Unit Culture
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Why Measure Unit Culture?
• Determine how bedside staff are feeling related to
communication and recognizing defects
–
–
–
–
Diagnose and assess the current status of patient safety culture.
Identify strengths and areas for patient safety culture improvement.
Examine trends in patient safety culture change over time.
Measure/evaluate the cultural impact of patient safety initiatives and
interventions.
• CUSP is the intervention that will help you improve culture results
– Results will be discussed during coaching call 5 – unit culture action plan
development
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AHRQ’s Hospital Survey on Patient Safety
(HSOPS)
42 items assess 12 dimensions of patient safety
culture
1. Communication openness
2. Feedback & communication about error
3. Frequency of event reporting
4. Handoffs & transitions
5. Management support for patient safety
6. Nonpunitive response to error
7. Organizational learning--continuous improvement
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AHRQ’s Hospital Survey on Patient Safety
(HSOPS)
8. Overall perceptions of patient safety
9. Staffing
10. Supv/mgr expectations & actions promoting patient safety
11. Teamwork across units
12. Teamwork within units
Patient safety “grade” (Excellent to Poor)
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HSOPS Process
• Each Team Leader must identify how many staff members on the unit will
be surveyed – all staff should take the survey!
– Physicians
– Licensed Staff – RNs, RTs, LPNs, etc.
– Non-licensed Staff – CNAs, Unit Clerks, Housekeepers, etc.
• Team leaders will be asked to provide this information in the postcoaching call survey (will be emailed to you)
• MOCPS will email a URL/link to each Team Leader– team leaders will
distribute this link to all staff targeted to take the survey
• The survey will be open between November 29th and December 20th, 2010
• Goal is reaching a 60% response rate
• Results will come into MOCPS – reports will be sent to each team leader
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HSOPS Process:
If the unit has recently completed a safety survey
• If units have already taken a patient safety culture survey and
the following is true:
– A) survey occurred within the last 6 months
– B) unit received at least a 60% response rate
– C) there have been no major staff, leadership, or structural changes in the
unit, such as
• Staff turnover/layoffs
• Changes in medical staff or medical staff model (i.e. open vs. closed unit)
• Change in manager
. . . then you do not need to take it again – those results can
be used for the action planning we will do in Coaching Call 5
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HSOPS Process:
Getting a 60% Response Rate
• Value it!
• Explain to staff why filling out the survey is so important – showcase
specific examples from the unit that help validate that culture
improvement is important for all staff
• Make the survey accessible to all staff
– Email the URL vs. Putting URL on one computer accessible to all staff – both are options
• Make it a challenge – if the unit reaches 60%, get some sort of incentive
(i.e recognition, small gift, pizza or ice cream party, etc.)
• MOCPS will send weekly response rate reports during the 3-week survey
period
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What are your next steps?
• Conduct First or Second team
meeting
• Educate team on the
Science of Safety and Staff Safety
Assessment; establish plan on how
to roll out to unit staff and execute
• Review HSOPS tool and define
process for administration
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Module 1: The Basics of CUSP
• Session 1:
• Session 2:
• Session 3:
• Session 4:
• Session 5:
• Session 6:
Forming a CUSP team and
Science of Safety Education
Staff Safety Assessment and
Measuring Culture
Learning from a Defect-part 1
Learning from a Defect-part 2
Safety Culture Results and
Action Planning
Evidence-based Practice, Just
Culture and CUSP team tools
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Be Courageous
We all are responsible for the safety of our
patients----Own the issues
• “If not this, then what??”
• “If not now, then when?”
• “If not us, then who??”
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Notes on Hospitals: 1859
“It may seem a strange principle to enunciate as
the very first requirement in a Hospital that it
should do the sick no harm.”
Florence Nightingale
Advocacy = Safety
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A Healthcare Imperative
“In medicine, as in any profession, we must
grapple with systems, resources,
circumstances, people-and our own
shortcomings, as well. We face obstacles of
seemingly endless variety. Yet somehow we
must advance, we must refine, we must
improve.”
Atul Gawande in his book, Better: A Surgeon’s Notes on Performance
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Questions?
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