nsqipcusp7 21 12(share).ppt [read-only]web2.facs.org/download/makary-wick_2.pdf1. science of safety...
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© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
Comprehensive Unit Based Safety Program(CUSP)
Elizabeth C. Wick, M.D.
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BackgroundNSQIP report 2009
5
Johns Hopkins
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Comprehensive Unit-based Safety Program (CUSP)
– Educate and improve awareness about patient safety and quality of care to ALL PROVIDERS (techs, nurses, anesthetists, surgeons, residents)
– Empower staff to take charge, put their local wisdom to use, and improve safety in their work place
• Their voice NEEDS to be heard
– Partner unit with an actively participating hospital executive
• Send a message to frontline staff about the importance of the work
• Provide resources for unit improvement efforts
• Hold team accountable for improvement
– Provide tools to monitor outcomes, investigate and learn from defects and improve teamwork and safety culture
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Successful Efforts to Reduce Preventable Harm
• Michigan Keystone ICU program– Reductions in central line-associated blood
stream infections (CLABSI) 1,2
– Reductions in ventilator-associated pneumonias (VAP) 3
• National On the CUSP: Stop BSI program
1. N Engl J Med 2006;355:2725-32. 2. BMJ 2010;340:c309. 3. Infect Control Hosp Epidemiol. 2011;32(4): 305-314.
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CUSP for Surgery
Comprehensive Unit Based Safety Program
Component1. Science of safety education
2. Safety culture assessment
3. Senior executive partnership
4. Safety Assessment
5. Implement teamwork and communication tools
Armstrong Institute for Patient Safety and Quality
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Patient Safety Culture
• Domains of Culture• Speaking Up• Job Satisfaction• Burnout• Perceptions of Management• Working Conditions• Teamwork
Makary M, et al., Annals of Surgery, 2006
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Perceptions of Teamwork Vary Among Operating Room Providers
Armstrong Institute for Patient Safety and Quality10
Makary et al. JACS 2006
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COLORECTAL SURGERY CUSP
Armstrong Institute for Patient Safety and Quality
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Kevin Driscoll CRNACRNA Lead
Deb Hobson RN“Coach”
Tracie Cometa RNLead RN
Sean Berenholtz MDAnesthesia Lead
Lucy Mitchell RNNSQIP SCR
Elizabeth Wick MDSurgery Lead
Renee Demski MBASenior Director QualityJohns Hopkins Medicine
Executive
NSQIPOutcomes
Steph Mullens CSTLead Tech
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What are the safety problems?
Safety Issue Identified(% response)Infection Control (68%)
Coordination of Care (12%)
Communication and Teamwork (12%)
Equipment/ Supplies (2%)
Policies/Protocols (2%)
Education/Training (2%)
Wick et al. JACS, 2012, in press
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Gentamicin
Interventions:• Increased amount of
gentamicin available in the room
• Added dose calculator in anesthesia record
• Educated surgery, anesthesia and nursing in grand roundsDespite >95% compliance on SCIP
Armstrong Institute for Patient Safety and Quality
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Skin Preparation
Interventions:• Chlorehexidine wash cloths given to patients pre-
operatively
• Surgical skin preparation standardized to chloraprep(even in patients with ostomies)
• Prep responsibility shifted to circulating nurse from resident
• All nurses trained on chloraprep applicationArmstrong Institute for Patient Safety and Quality
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Normothermia
Interventions:• Confirmed that
temperature probes were accurate (trial comparing foley and esophageal sensors)
• Initiated forced air warming in the pre-operative area
Armstrong Institute for Patient Safety and Quality
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Separation of “Dirty” and “Clean”Instruments
Intervention:• Built separate tray of
instruments used for bowel anastomosis
• Extra suction and bovie tip and gloves opened and changed after anastomosis
• Educational sessions with scrub techs and nurses about instrument separation
• Audits and education on the spot
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0
5
10
15
20
25
30
35
40
45
Q3 2009 Q4 2009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011
Col
orec
tal S
SI ra
teSSI Rate and Interventions
Quarter 3Skin preparation protocolPre-op wash clothes
Quarter 4CUSP kickoffAntibiotic deficiencies addressed
Quarter1Pre-op warmingEnhanced sterile techniqueIntervention checklist
42 %
17 %
29 %26 %
16 %20 % 19 % 18 %
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HIGHLIGHTS FROM YEAR 2EXPANDING THE SCOPE
Armstrong Institute for Patient Safety and Quality19
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Building Capacity:Armstrong Institute Patient Safety Fellowship
Tracie Cometa, RN Kevin Driscoll, CRNA
• 16 hrs per week (Jan-June 2012)• 8 hrs classroom training on patient safety• 8 hrs protected time for quality improvement projects
8/7/201220
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Briefing and Debriefing
• Team developed new form based on needs
• RN given protected time to address concerns raised during briefing and debriefing
• Candid discussion with surgeons about effective strategies for briefing/debriefing
• Ongoing observations of briefing to address defects
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Standardization of perioperative steroid use
Lucy Mitchell RN,MSN, SCR– Noted 50% SSI rate in patients on steroids
• Pharmacy led audit of perioperative steroid use demonstrated 50-200mg hydrocortisone administered intra-op
Raymon Lamore Pharm D.
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Engaging Other Providers: Peer Outcome Reports
Armstrong Institute for Patient Safety and Quality23
• Provider specific data compared to peers• All surgeons performing > 10 colorectal procedures per year• Sets the stage that problem is preventable and a social problem
Surgeon ID
ACS NSQIP (defined
variables) 30-Day Mortality
Rate
Superficial Incisional
SSI
Deep Incisional
SSIOrgan/Space
SSIWound
DisruptionPulmonary Embolism
Urinary Tract Infection
Transfusion Intraop/ Postop Sepsis
Septic Shock
1
2
3
Dr. Wick
5
6
7
8
Site Total 9 2.3% 61 15.4% 2 0.5% 21 5.3% 5 1.3% 10 2.5% 20 5.0% 69 17.4% 13 3.3% 9 2.3%
Comparison480 3.3% 1,049 7.2% 206 1.4% 649 4.5% 206 1.4% 130 0.9% 572 3.9% 2,448 16.8% 755 5.2% 384 2.6%
TARGETED PROCEDURE MODULE
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Lessons Learned
• Harm is preventable
• Change can not be “top down”
• CUSP sends a clear message, all provider opinions and ideas are important and essential for improvement
• Better teamwork better outcomes better culture and teamwork
• Positive culture empowers frontline staff to take ownership of patient safety and achieve unprecedented improvements
• It takes time and commitment
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Johns Hopkins Hospital Motto
Our experience: hospital level interventions(SCIP) pale in comparison to interventions at the work unit level (CUSP)
We embrace local wisdom in the Colorectal OR’s
25© JHU and JHHS, 2009