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.
