the johns hopkins comprehensive unit-based patient safety program (cusp) peter pronovost, md, phd,...
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The Johns Hopkins Comprehensive Unit-based Patient Safety Program
(CUSP)
Peter Pronovost, MD, PhD, Johns Hopkins Univeristy
How can this happen?
Improvements in safety represent the greatest opportunity to improve patient care
How can we improve
“Every system is perfectly designed to achieve the results it gets”
Aviation Accidentsper million departures
Primary accident causes (%)
0 10 20 30 40 50 60 70 80
Flight Crew
Airplane
Maintenance
Weather
FAA
Other
Today, pilots can fail their certification based on poor
interpersonal, or “non technical” aspects of their performance.
Teamwork by Edict:
Lessons Learned:
Focus on interpersonal improvements Frontline staff must assume responsibility for
quality and safety Safety interventions must be goal directed Culture changes incrementally Document (measure) improvements
Johns Hopkins Comprehensive Unit-based Patient Safety Program
(CUSP)
The Johns Hopkins Comprehensive Safety Program
1. Evaluate culture of safety
2. Educate staff on science of safety
3. Identify staff’s safety concerns
4. Executive adopt an ICU
5. Prioritize improvement efforts
6. Implement improvements
7. Share stories and disseminate results
8. Evaluate culture
Summary of Science of Safety
The safety problem is large We will make mistakes We must focus on systems rather than people We need a culture to identify what is broken and
fix it Leaders control the potential to change systems
www.icusrs.org
NEJM
Evidence Regarding the Impact of ICU Organization on Performance
Physicians Nurses Pharmacists
Pronovost JAMA 1999, 20002Pronovost JAMA 1999, 2002; Pronovost ECP 2001
Incident Reporting
http:icusrs.org
What can we do to improve safety
Accept that we make mistakes Focus on Systems
– Prevent mistake from occurring– Make mistake visible– Mitigate harm should it occur
Helmreich, Nolan
To prevent mistakes
Create culture of safety Reduce complexity Create independent redundancy to ensure
key processes occur– Evidence-based therapies– Bottle necks
Culture in Safe Organizations
Commit to no harm Focus on systems not people Communication/teamwork
– Assertive communication– Teamwork– Situational awareness– Disclosure
Celebrate safety– Workers viewed as heroes
Teamwork Climate Across Positions
Res
pir
ato
ry T
her
Bed
sid
e N
urs
e
Nu
rse
in C
har
ge
Nu
rsin
g A
ssis
tan
Res
iden
t
Oth
er
ICU
Ph
ysic
ian
0
10
20
30
40
50
60
70
80
90
100
R e sp ira to ry T h e r B e d sid e N u rse N u rse in C h a rg e N u rsin g A ssista n R e sid e n t O th e r IC U P h ysic ia n
% o
f res
pond
ents
with
in a
clin
ic re
port
ing
good
team
wor
k cl
imat
e
ICU Physicians and ICU RN Collaboration
51%
88%
0
10
20
30
40
50
60
70
80
90
100
K P L &D
RN rates ICU Physician ICU Physician rates RN
% o
f res
pond
ents
repo
rtin
g ab
ove
adeq
uate
team
wor
k
Johns Hopkins Comprehensive Patient Safety Program
STAFF SAFETY SURVEY
Thank you for helping improve safety in your workplace!
Please describe how the next patient in your work area will be harmed. Please describe how we can prevent this harm. Please describe how we can make the potential harm visible before it happens. If the patient were to suffer this harm, how could we reduce the harm?
Name: Role Date: Unit:
Please describe how you prevented a patient from being harmed.
ISSUES IDENTIFIED ACROSS ICU’S
Patient transport Medication errors Communication Central line infections
Percent Understanding Patient Care Goals
00.10.20.30.40.50.60.70.80.9
1
1 2 3 4 5 6
Residents
Nurses
Implemented patientgoals sheet
Impact on ICU Length of Stay
0
0.5
1
1.5
2
2.5
Avg
. LO
S (
day
s)
ICU LOS
654 New Admissions: 7 Million Additional Revenue
Daily Goals
ICU catheter-related blood stream infections
NNIS Mean
Education
Line Cart
Checklist
0
10
20
30
Jan
Feb
Mar
Ap
rM
ay Jun
Jul
Au
gS
epO
ctN
ovD
ecJa
nF
ebM
arA
pri
lM
ayJu
ne
July
A
ugu
st
Rat
e/1,
000
Cat
hete
r da
ys
Figure 1: Percent of Charts with Medication Errors Identified per Week through Medication Reconcillation Process*
0%
10%
20%30%
40%
50%
60%
70%80%
90%
100%
Week
Series1 94% 94% 50% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 50% 0% 0% 13% 0% 0% 0% 0% 0% 0% 0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Culture
Safety Climate Across Orgs
0
10
20
30
40
50
60
70
80
90
100
4 3 6 5 1 2 8
% o
f res
pond
ents
with
in a
clin
ical
are
a re
port
ing
good
saf
ety
clim
ate
What can you do:
The safety program provides a practical, goal directed tool to improve safety culture and lead to measurable improvements in safety
NEXT STEPS
Communication
– Safety Tales
– Sharing Lessons Learned
Additional Training
Nursing units and Departments
Medical/nursing students
Is Safety your Hedgehog Concept
What can you be great at
What are you passionate about
What is importantJim Collins
Who is willing to shave their Head
Who is willing to commit to improving patient safety
