This course provides students with a set of tools and methodologies to plan and initiate a Problem Solving or Quality Improvement project. The first module presents methods for selecting, scoping and structuring a project before it is even initiated. It also introduces the project classifications of implementation and discovery. The second module describes the A3 problem solving methodology and the tool itself. Further in that same module, the student is shown tools to identify problems in flow, defects, and waste and to discover causes, brainstorm, and prioritize interventions. Module 3 shows a methodology within the implementation class. These methods are designed to overcome emotional and organizational barriers to translating evidence-based interventions into practice. The fourth and last module looks at one more way to approach improvement projects in the discovery class. These tools are specifically for new, out-of-the-box design thinking.
CUSP As Adaptive Work
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来自 Johns Hopkins University 的课程
Planning a Patient Safety or Quality Improvement Project (Patient Safety III)
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与讲师见面
Bob Hody
In this video, we're going to talk about
the Comprehensive Unit-based Safety Program or CUSP to address Adaptive Work.
In any successful quality improvement project,
we need to address both the Technical Work as well as the Adaptive Work.
The Technical Work is that long list of
evidence-based therapies that we know patients should be receiving.
In many quality improvement programs,
our teams work towards incorporating these technical interventions into policies,
procedures, and protocols or even
checklists to help ensure that patients receive the evidence-based therapies they should.
But we know that these strategies only work if people use them.
To be successful, we also need to address the Adaptive Work or those values, attitudes,
and beliefs on behalf of frontline staff and other important stakeholders,
they drive everyday decisions within our healthcare organization.
Within our quality improvement collaborative,
working with hospitals across the country,
we always address and coach them to
address not just the Technical Work but also the Adaptive Work.
And in the Adaptive Work,
we help them implement the Comprehensive Unit-based Safety Program or CUSP.
CUSP is a practical approach to tap into the wisdom of our frontline staff
to improve both teamwork and safety culture.
So what is CUSP?
CUSP is a five-step program that builds upon the principles of
high reliability organizations and has
been validated to improve both teamwork and safety culture.
CUSP starts off in a single unit within an organization and then is spread.
It's exceedingly important for the frontline staff to be intimately
involved in these efforts and we need to
build strong relationships or partnerships with others within
the organization depending upon the quality improvement program that we're focusing on.
In our story of preventing central-line associated bloodstream infections, for example,
we knew that we had to partner with other experts within
our organization including our infection prevention staff
or hospital quality and safety leaders,
as well as our nurse educators and physician leaders to
implement a successful program to prevent central-line associated bloodstream infections.
CUSP is a five-step iterative process.
It's not as though we can go through each of
these steps and then magically our culture is going to be improved,
but rather, this is a sequence of steps that,
over time, builds and becomes deeper and richer.
The first step of the CUSP program is to
educate staff in that unit on the science of safety.
The idea here is that to ensure the providers
know that safety is the property of the healthcare system.
Every system is perfectly designed to achieve the results that it does.
The second step is to identify defects or to tap into the wisdom of our frontline staff,
to really understand what are
their patient safety concerns within this healthcare organizations.
In our efforts to prevent ventilator-associated pneumonia, for example,
we often asked our teams,
how do you think that the next patient is going to
develop a ventilator-associated pneumonia?
Or what do you think can be done to try to get patients off the ventilator faster?
Similarly, for prevention of surgical site infections,
we asked our frontline staff,
how do you think that patients will develop
a surgical site infection in this clinical area?
And what do you think that we can do to try to prevent those infections?
This step of asking our frontline staff for
their opinions and their insights is exceedingly deceptive,
it's simple but yet important.
Most of our frontline staff, as it turns out,
oftentimes don't feel like they're part of our quality improvement project.
In our efforts to coach other teams focusing on
prevention of healthcare-associated infections,
we often hear from our frontline staff that they've worked within organizations for
up to 30 years and nobody has
ever asked them what they think can be done to improve care.
This second step of CUSP,
of asking staff what they think they can do to improve care,
is exceedingly important and goes a long way towards identifying local defects as well as
engaging our frontline staff to actively
participate in these quality improvement efforts and help them feel valued.
The third step of the CUSP program is for the frontline team to
partner with a senior executive and to meet with them at least monthly.
Senior executives within our organizations can include anyone from the C-suite, CFOs,
CNOs, CMOs for example, but really,
anybody who knows how to make things happen within your organization.
You see, the role of the senior executive is not to
bring additional resources to the quality improvement team
but rather to help align
the quality improvement team goals with that of the organizational priorities.
Senior executives can also be exceedingly helpful in helping this frontline team navigate
some of the complex bureaucracies that exist
within our organizations that make change challenging.
Finally, senior executives help hold
the frontline staff CUSP team
accountable for what they say they're going to do and, in turn,
the CUSP team can hold the senior executive accountable for helping to facilitate,
identify and mitigate barriers to these successful quality improvement programmes.
The fourth step of the CUSP program is to help learn from mistakes.
Without a doubt, bad things are going to happen within our organization.
But we need to do a better job of not just
recovering from those mistakes but truly helping to
work towards understanding those system-level defects that contributed to these mistakes.
Learning from defects is a simple tool that will
be presented in another video and includes three steps.
It asks the frontline's team to get together when a mistake has
happened and to ask what happened,
why did it happen,
and what do you think we can do to try to prevent this from happening again.
And then finally, how do we know that our interventions are going
to be effective for preventing this defect from happening again?
Simple tools like learning from defects can be
a powerful strategy for getting frontline staff to begin to work
together to resolve some of
these complex patient safety challenges that we have within our organizations.
The last step of the CUSP program is to improve teamwork and safety culture by
implementing tools that could help us begin to
improve teamwork and communication on a local level.
We've shared with you a number of tools that we use at
the Armstrong Institute for the Prevention of
central-line associative bloodstream infections
and ventilator-associated pneumonias, for example.
We talked in detail about the
daily goals form that's used every day on every patient within the ICU.
Implementation of CUSP has been associated with
dramatic improvements in both teamwork and safety culture.
In our Michigan Keystone ICU program,
the percent of units that were in a need-improvement zone,
defined as any clinical area where less than three out of
five providers would agree that we have good teamwork,
our safety climate dramatically improved with the implementation of CUSP.
CUSP implementation has been associated with
a dramatic reduction in catheter-related bloodstream infections,
a 71 percent reduction in ventilator-associated pneumonias,
10 percent reduction in all-cause mortality throughout Michigan hospitals,
a 40 percent reduction in
central-line associated bloodstream infections and the National Central-line
Associated Bloodstream Infection Prevention Project
including over a thousand ICUs across the country,
a 1.1 million dollar annual savings for
the average hospital participating in these quality improvement programs,
and a significant reduction in surgical site infections.
Furthermore, CUSP implementation has been
associated with significant improvements in teamwork
and safety climate as well as nurse turnover rates within our organization.
Not surprisingly, CUSP implementation helps our frontline staff feel valued
by asking for their opinion and helping them
become intimately involved in our quality improvement efforts.
Far too often, our staff feel like quality improvement is something that is
being done to them rather than it being done with them.
CUSP implementation helps to address some of these issues,
help our frontline staff feel valued,
an important part of the team, and indeed,
many of us think that CUSP implementation is likely as important,
if not more important,
than the implementation of tools like checklists and protocols and
policies for the prevention of healthcare-associated infections.
Without a doubt, the best way forward is that many of
these harms including healthcare-associated infections
are preventable and they need to be viewed as defects.
To be successful, we need to be informed by
the science and make sure that we get this science right.
Far too often, we focus on the Technical Work but we also need to focus
on that Adaptive Work to improve values,
attitudes and beliefs on behalf of our frontline staff and CUSP is
an exceedingly effective strategy for improving adaptive teamwork.
Finally, this work should be led by clinicians and supported by management.
We need to do a better job of tapping into the wisdom of
our frontline staff and CUSP is an
exceedingly effective at tapping into the wisdom of our staff.
Finally, to be successful,
we need to do a better job of building capacity within our organizations.
Many of us in professional school,
nursing school or medical school didn't receive the appropriate training
or skills that we needed to alleve adaptive challenges within our organization.
As part of our mission within Johns Hopkins Medicine,
our goal is to build capacity.
We need to do a better job of educating our frontline staff,
and within our organization,
our goal is to educate all of our staff with these principles
of safe-system design similar to the first step of our CUSP program.
But we also need to have staff within our organizations that dig a little bit deeper,
that have additional training to help lead some of these quality improvement efforts.
And this, indeed, for many organizations is an ongoing journey.
