Problem statement:The senior executive is a crucial member of your CUSP for VAP team. He or she has valuable leadership and problem solving skills. Yet the senior executive may not be familiar with your clinical area at the start of the project, and may even be intimidated by it. You can help engage your executive by familiarizing him or her with your clinical area and your team’s safety priorities.

Purpose of this tool: You can use this tool at the beginning of your first Executive Safety Rounds to get your senior executive up to speed. It will help you present clinical area information and safety priorities in a concise way.

Please adapt this tool: This tool was designed to facilitate communication with their senior executive. Please modify this tool to best fit your team’s needs. As always, we welcome your feedback and encourage you to share your experiences with other CUSP teams in the project.

How to use this tool: The CUSP for VAP team lead or a designee should input clinical area information as indicated in this tool. (Examples are included to show you how the tool might look when it’s completed). Make copies of this tool and hand it out to everyone at the start of your first Executive Safety Rounds meeting. You can refer to it as you highlight your clinical area’s characteristics and safety priorities during the meeting.

Clinical Area:
CUSP for VAP Team
Senior Executive Partner:
Physician Champion:
Nurse Champion:
Respiratory Therapist Champion
Other Champion:
List Other Team Members

1.HSOPS Assessment Composite Scores

  • Share your HSOPS Assessment scores with your senior executive. Examples of information you might share are described below.

Survey Close Date:

Number of respondents:

Response Rate:

Tip: You can find the number of respondents and response rate on page 3 of your HSOPS aggregate report.

  • You can copy the composite scores graphs from pages 6 and 7 of your HSOPS aggregate report, below. (The graph on page 6 looks like this):

Sensemaking Tip: Consider providing a brief summary of your HSOPS results, highlighting important points or culture score results that you’d like to bring to your senior executive’s attention.

2.Collated Staff Safety Assessment (SSA) Responses

  • In Step 2 of the CUSP for VAP manual your team administered the SSA to your entire staff, and grouped responses by commonly identified defects. You can put that information in this table to help your senior executive get familiar with your clinical area’s safety priorities.
  • Consider summarizing important take-homes in one or two sentences to help your senior executive focus on critical issues, and remember to provide your senior executive with a bit of background on the SSA.

Prioritized Safety Issues
(Based on Collated Staff Safety Assessment Responses)

Response Category / Number / %
E.g., Communication & Teamwork
E.g., Infection Control
E.g., Equipment
Total

Staff Safety Assesment Responses

  • You can include some SSA responses here to give your senior executive a more nuanced understanding of your frontline staff’s perspective on safety issues.

How the next patient will be harmed?
How will the next patient develop a VAP?
Category / Comments
E.g., Communication & Teamwork /
  • Ex: Lack of communication between physicians, nurses and anesthesia providers
  • Ex: Everyone not sharing the same information

E.g., Infection Control /
  • Ex: Oral care with chlorhexidine is not documented well in the patient record

E.g., Equipment/ Supplies /
  • Ex: Non-invasive ventilatory equipment is only available through central supply.
  • Ex: Subglotticendotracheal tubes are not readily available on the unit.

How can we prevent this harm?
How can we prevent the next VAP?
Category / Comments
E.g., Communication & Teamwork /
  • Ex:Take the completion of Daily Goals and Morning Briefings seriously and when conduct these when everyone is available
  • Ex: Empower all team members to speak up when VAP process measures are being skipped.

E.g., Infection Control /
  • Ex: Assure that chlorhexidine is used 2 x per day for oral careEx: Assure that everyone practices good hand hygiene before entering the patient’s room

Ex. Equipment/ Supplies /
  • Ex: Assure that non-invasive ventilatory equipment is stored on the unit
  • Ex: Assure that subglotticendotracheal tubes are well-stocked in the code cart and in the supply areas

Sensemaking of the CUSP for Safe Surgery mrespondents and response rate on page 3 of your HSOPS aggregate report.1111111111111111111111111Tip: Consider building on staff’s suggestions for improvement with specific recommendations for your senior executive.

3.Pertinent Clinical Area Information

  • You can include a few bullet points or graphs here with information about your clinical area that your executive may not know. Information may include staff turnover rate, safety event rates, VAE/VAP infection rate, or other pertinent data.

SensemakingTip: After completing this tool, consider supplementing it with a short summary on the safety issues that you will be exploring in your Executive Safety Rounds. This summary can identifyyour team’s objectives as you begina partnership with your senior executive.