Best Practice Summary
The Johns Hopkins Medicine Comprehensive Unit-Based Safety Program (CUSP)
Resident: Christopher T. Ogren
Organization: The Johns Hopkins Hospital
Preceptor: Kelly S. Cavallio
Points of Contact:
Kelly Cavallio, Administrator, Ambulatory Services
(410) 502-5285,
Paula Kent, Patient Safety Coordinator
(443) 287-0018,
Groups Involved with the Project:
The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Hospital and various departments throughout Johns Hopkins Medicine
Executive Summary
The Comprehensive Unit Based Safety (CUSP) program is a 5-step patient safety framework that Johns Hopkins Medicine (JHM) has been utilizing since the early 2000s. The primary goal of this program is to empower staff to take responsibility of safety in their units while changing the unit’s workplace culture. The various units of JHM have implemented many effective safety interventions via education, access to health system resources, increased awareness and toolkits. Forty units within JHM currently engage in CUSP and, through partnerships with the state of Michigan, CUSP has been implemented in over 100 ICUs to target catheter related blood stream infections. CUSP has proven to be a sustainable and successful patient safety framework by targeting effort at the unit level with the support of the organization as a whole.
Objective of the Best Practice: In today’s healthcare setting, patient safety has become a focal point for healthcare organizations around the world. The Comprehensive Unit-Based Safety Program (CUSP) is a program designed to implement safety improvements, but more importantly, change workplace culture with regard to safety practices in the healthcare setting. This 5-step program drives culture change primarily through education and awareness of safety issues while empowering individuals to address and improve safety. Additionally, the Armstrong Institute for Patient Safety and Quality provides intervention toolkits and, when necessary, access to organizational resources to improve patient safety. The ultimate goal of CUSP is to create sustainable patient safety improvements by creating a culture of safety that drives units to achieve organizational and national patient safety goals.
Background: As with many patient safety initiatives over the last decade, CUSP traces its beginnings to the 1999 Institute of Medicine’s groundbreaking report, “To Err is Human”. Dr. Peter Pronovost, MD, PHD, an anesthesiologist and critical care medicine physician, spearheaded patient safety efforts at Johns Hopkins Medicine (JHM). Dr. Pronovost began his efforts as part of the JHM Quality and Safety Research as well as the Center for Innovation in Quality Patient Care. Both groups, as well as other partners in the university and health system, have since been combined into the Armstrong Institute for Patient Safety and Quality. Dr. Pronovost set out to assess and improve patient safety at JHM by leveraging his role in the patient safety domain along with the mounting case for improved safety and quality in the hospital setting. The first goal in improving patient safety at JHM was to create a culture of safety by implementing CUSP at the work unit level and empowering those unit level workers to identify and eliminate safety hazards that could adversely affect patients.
Literature Review: The landmark IOM report, “To Err is Human” shed light on the growing problem of medical errors in healthcare delivered in the United States. The IOM report (1999) estimates that between 44,000 and 98,000 people die in hospitals each year due to preventable medical mistakes. Intensive care units, operating rooms and emergency rooms are particularly susceptible to high error rates with serious consequences. In addition to the human toll, there is an estimated cost of $17 billion and $29 billion per year arising from additional care resulting from the error, disability and lost income/productivity. Another non-monetary cost is the loss of faith in the system incurred by patients and healthcare givers alike. Furthermore, the study found that the issue of medical errors is complicated by fragmented care delivery in the U.S., challenges within the medical liability system that impedes identification and resolution to errors and the fact that there is currently very little incentive for providers and healthcare organizations to improve safety and quality. The report found that most errors are due to faulty systems and processes rather than recklessness of groups or individuals. (IOM report brief, 1999). The IOM also noted in a later report, Crossing the Quality Chasm (2001), that: “the biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are not treated as personal failures, but as opportunities to improve the system and prevent harm”. Therefore, it is well within an organization’s grasp to galvanize employees to embrace a culture of safety while designing sustainable processes that improve patient safety and reduce medical errors.
The IOM report created tidal wave of initial momentum but assessing progress in patient safety has been difficult. Watcher (2004) analyzed the state of patient safety 5 years after the IOM report and noted that while progress is occurring, funding for safety dwarfs that of medical progress and few investments have been made toward safety outside of IT systems. He further notes that hospitals lack the capital to invest large amounts in patient safety so the business case for improving safety is current not adequate to drive large scale change. In 2005, a study on patient safety systems utilized surveys to assess patient safety progress in all acute care hospitals in Utah and Missouri at two different points in time, 2002 and 2004. A sum of 7 latent variables (i.e. CPOE, patient safety policies, root cause analysis, etc.) was used to assign a patient safety status to the hospitals. The study found modest implementation of patient safety systems with some hospital reporting a regression with regard to progress. Additionally, 74% of hospitals reported a full implementation of a written safety plan while 9% reported no such plan (Longo, Hewett, Ge, & Schubert, 2004). However, literature on patient safety and medical errors has increased in the years since the IOM report. One study (Stelfox, et. al., 2006) assessed MEDLINE articles published between 1994 and 2004 and found that the rate of patient safety publications increased from 59 to 164 per 100,000 MEDLINE publications with increased rates of publication for all types of patient safety articles. Further, they found an increase in original research, patient safety research awards and a shift from malpractice to organizational culture as the most frequent subject of patient safety publications. With increasing literature on patient safety, a large public desire for improvements to patient safety and increasing regulation using quality as a benchmark, successful and sustainable patient safety programs are a necessity in the rapidly changing healthcare landscape.
Implementation Methods: The initial version of CUSP was an 8-step program consisting of the following steps: (1) culture of safety assessment; (2) sciences of safety education; (3) staff identification of safety concerns; (4) senior executive adopted a unit; (5) improvements implemented from safety concerns; (6) efforts documented/analyzed; (7) results shared; and (8) culture reassessment. The program was implemented in the JHH Weinberg ICU (WICU) while another surgical ICU (SICU) served as a control in the quasi-experimental design of the initial study. Six months later the program was implemented in the SICU. The units were chosen because both are high risk areas where mistakes are common and Dr. Pronovost is an attending intensivist in both ICUs. CUSP took guidance from the Institute for Healthcare Improvement’s Quantum Leaps in Patient Safety program to create a safety program that: (1) could be implemented sequentially in work units, (2) would improve the culture of safety, (3) would allow staff to focus safety efforts on unit-specific problems, (4) would help staff implement system wide safety initiatives, and (5) would include rigorous data collection to allow for publication. Central to the process was creation of the unit team which included a physician, nurse, and senior executive as a base but allowed for participation of pharmacists, respiratory therapists and other staff on the unit as well (Pronovost et.al, 2005).
The first step was to conduct a cultural survey with regard to how the staff perceives the organizations commitment to patient safety. A CUSP champion delivers a 40 minute safety presentation to all staff on the unit during step 2 of the program. The presentation used guidance from the “To Err is Human” report to address many issues such as importance of patient safety, improving systems rather than blaming caregivers, and stressing the importance of speaking up when one observes a patient safety issue. Step 3 involved addressing staff concerns via an open ended survey and compiling those results and an action plan for addressing them. In Step 4, a senior executive adopts a unit and this executive becomes part of the CUSP team, meeting with them once a month. Identification of a senior executive is critical as it serves a multifaceted role to: remove barriers to system changes, provide resources improvements, provide coaching/mentoring, and display leadership’s commitment to staff and improving the culture of safety. Step 5 is implementing improvements based on institutional safety priorities while step 6 is documenting the results of aforementioned improvements. Step 7 is to share stories in order to promote organizational learning and disseminate valuable improvement efforts. Finally, step 8 brings the process full circle and repeats the cultural survey (within 6 months) to assess improvement in safety climate. Two interventions were identified and implemented in step 5 of the pilot program. First, a short term goals sheet was developed in order to help care staff increase transparency and gain consensus on the work needed to be accomplished in order to discharge a patient and mitigate safety concerns throughout the process. Additionally, a tool was developed to reduce medication errors in transfer orders. This tool allowed the discharging nurse to validate the patient’s medication information on discharge and any discrepancies were addressed with the patient’s physician prior to discharge. The results of the CUSP implementation were assessed via measurements of nursing turnover, ICU length of stay and differences in the beginning and ending culture assessment surveys (Pronovost et.al, 2005).
Results: The pilot CUSP program generated a number of positive results. The safety climate assessment increased from 35% to 52% in the WICU and 35% to 68% in the SICU. The CUSP initiative also identified common issues among both units including poor communication between ICU providers, medication errors, and lack of trained patient transport teams. These issues were separated into two categories: minimal resources needed for improvement and additional resources needed for improvement. This allows CUSP teams to immediately implement easy fixes should the need arise to wait for more significant resources to address bigger problems. Inadequate communication during the patient transfer process was identified as a significant safety risk and short term goal sheets were developed to improve communication between patients, family members and physicians. Medication reconciliation errors in the WICU (90% of orders) and SICU (40% of charts), were both eliminated as a result of the routine nursing discharge process. The intervention also had a positive effect on nursing turnover rates as well as ICU length of stay and those results are summarized in table 1 below. It is important to note that changes in nursing turnover were not statistically significant despite decreases in both nursing turnover and ICU length of stay (Pronovost et.al, 2005).
The success of the pilot program has led to the adoption of CUSP by 40 units at the JHH as well as units in other healthcare organizations. The current iteration of CUSP contains 5 steps, with some of the original steps lumped into pre-CUSP work that largely involves assembling the team, identifying an executive and gathering initial information on the unit and existing safety culture. The current CUSP framework consists of the following steps: (1) Train staff in the science of safety, (2) Engage staff to identify defects, (3) Senior executive partnership/safety rounds, (4) Continue to learn from defects and (5) Implement tools for improvement. The Armstrong Institute website details the CUSP framework and maintains a running list of tools with the recommendation for units to adopt and implement 3 tools per year. (JHM CUSP website, 2013). In 2008, the Weinberg 4C unit implemented several interventions to reduce safety hazards and improve culture and, much like the original CUSP study, this unit improved safety culture and teamwork while reducing nurse turnover rate in the process. (Timmel et al., 2010). CUSP is not just local to JHH. After successfully reducing bloodstream infections in JHH ICUs, Dr. Pronovost partnered with the Michigan Keystone ICU Patient Safety Program, and rolled out the program in ICUs across Michigan. Specific interventions to reduce central-line associated bloodstream infections (CLABSIs) and ventilator-associated pneumonia (VAP) were implemented alongside a CUSP program during this collaboration. This program also sought to associate a cost with regard to a successful intervention and the program averted 29.9 CLABSIs and 18.0 cases of VAP annually. The cost of the intervention was estimated at $3,375 per infection, which is much less than additional healthcare costs of $12,208-56,167 that would result from these infections (Waters et al., 2011).
Conclusion: CUSP certainly meets all the requirements of a successful best practice. The program’s reliance on rigorous data collection and follow-up allows participants to track outcomes over time. CUSP is adaptable to the concerns of a given unit and JHM has proven this this program is replicable not only inside its walls, but in Michigan Keystone ICU program as well. CUSP continues to thrive at JHH in over 40 units. This program’s sustainment is not only due the fact that CUSP is institutionalized but the program allows for low cost interventions that reduce larger downstream expenses that would have resulted from errors. While patient safety programs are not new in 2013, The CUSP program was innovative at the time of its inception and continues to evolve to address the changing needs in the patient safety landscape.
The Department of Defense (DoD) Patient Safety Program (PSP) has come a long way in adopting many of the features of successfully patient safety programs such as CUSP (DoD PSP talking points, 2013). However, there are still items within CUSP that the MHS can use to improve their PSP. Integration of administrators and executives is a key feature of the CUSP program. The DoD PSP has methods to report safety issues up and get them solved but the CUSP program demonstrates that many problems can be solved at the lowest level if all the players are working towards a common goal. Implementation may be different depending on the service, but the MHS would be better served by a greater integration of staff on patient safety teams. Using the Air Force as an example, many administrators end up in silos and may not fully understand the healthcare and safety impact of finance or resourcing decisions. On the other hand, caregivers may not understand the administrative side well enough to remove barriers to patient safety. CUSP started on inpatient units but it also has application in the large number of outpatient centers in the DoD. The large elderly beneficiary population of the DoD provides many opportunities for mistakes and errors, even in an outpatient setting. CUSP provides a fantastic framework by which a cross functional team of caregivers, administrators, officers and enlisted personnel can continue to support the MHS Quadruple aim of Readiness, Population Health, Experience of Care and reducing Per Capita Cost.