CLABSI Supplemental Call Series

How CUSP Enables Nurse EmpowermentNovember 15, 2011

Presenters:Pat Posa, RN, BSN, MSA

Joanne Timmel, MSN, RN, NE-BC

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CLABSI Supplemental Call Series

Pat Posa, RN, BSN, MSASystem Performance Improvement Leader

St. Joseph Mercy Heath System

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CUSP Components

1. Form a unit CUSP team with executive sponsorship

2. Measure unit culture3. Educate staff on science of safety4. Identify defects using the staff safety

assessment; prioritize defects5. Learn from one defect per quarter6. Implement team and communication tools

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How is CUSP Different? It Empowers Nurses

• Driven by frontline staff – Nurses• Identifies problem areas: What staff think are

impeding patient care vs. what managers/directors think are priority areas

• Designed for bedside caregivers– Easy for busy staff to use– Unit drives its own quality

• Can complement other quality improvement methods – must use multiple tools

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St. Joseph Mercy Hospital’s Journey

• Keystone ICU: Statewide ICU collaborative (2003)• Multidisciplinary Keystone (CUSP) team met monthly• Annual culture assessment with staff developing action plans

to improve culture• Executive rounds• Learn from defects• Team/communication tools:– Multidisciplinary rounds with daily goals– Crucial conversation training– Structured huddles

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Best Practices:Learning from Defects Tool

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Best Practices: Engaging & Sustaining Nurse Involvement in CUSP

Huddles

• Enable teams to have frequent but short briefings so they can stay informed, review work, make plans, and move ahead rapidly

• Allow fuller participation of frontline staff and bedside caregivers, who often find it impossible to get away for hour-long improvement team meetings

• Keep momentum going because teams are able to meet more frequently

• Permits daily focus on unit outcomes and lets recovery begin immediately from defects (i.e., falls, sepsis)

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Components

Metric 1: Quality/SafetyMetric 2: Patient SatisfactionMetric 3: Operations

Daily Critical Communications

Information

Ideas in Motion

How to do it?•Beginning or mid shift•5-10 minutes•Lead by member of unit leadership team

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SICU Huddle Board

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Surgical Unit Huddle Board

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Lessons for Your Hospital: Strategies that Promote Nurses & Leverage CUSP

• Frontline staff are an integral part of the CUSP team• Teams should meet monthly• Nurses who work in the unit every day are the best people

to identify where there are opportunities to improve and how to improve

• Nurses need to be allowed to take responsibility for identifying problems and be given a forum and strategy to solve them– CUSP team– Learn from defects tool– Structured huddles

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A Healthcare Imperative

“In medicine, as in any profession, we must grapple with systems, resources, circumstances, people, and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, we must improve.”

Atul Gawande, Better: A Surgeon’s Notes on Performance

CLABSI Supplemental Call Series

Joanne Timmel, MSN, RN, NE-BC

Nurse ManagerThe John Hopkins Hospital

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Implementing CUSP: Assumptions & Prerequisites

• Certain beliefs predispose for success– Direct care staff are best able to identify

impediments to safe, efficient care– Staff value patient-centered care

• Manager has participative leadership style• Setting is important -- a room on the unit boosts

attendance• Broad Team: Pharmacist, social worker, PT & OT,

chaplain, environmental services, mid-level providers, residents, attending, administrator

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Implementing CUSP: Engaging the Team

• Define CUSP for your setting• Kick off with science of safety presentation• Ask the question: “How will the next patient be

harmed on our unit?”

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CUSP: How it Empowers Nurses in the Hospital

Nurses are empowered when —• They see change happen• Their concerns are affirmed• They develop a voice and can tell their story• They are supported by a unit culture that values speaking up

regarding patient safety

Nurses are empowered when they actually have power

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CUSP: Example of Empowerment

A surgical unit before CUSP — • Chaos• Unclear plan of care• Very poor communication with the surgeons • Patients frustrated and angry at nurses• Nurses felt powerless, so they left — high turnover

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CUSP: Example of Empowerment

Our first CUSP project:• Proposed cohorting• Implemented nurse-physician joint rounds• Developed a written daily goal sheet generated from rounds• Established other mechanisms for non-urgent communication

besides rounds • Continued to articulate collaborative culture by hosting First

Monday breakfasts

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CUSP: Example of Empowerment

Nurses now have a place to address day-to-day intransigent system problems•Medications not available when due•Pain control issues in admitted outpatients•Inpatient nurse/PACU nurse communication•Contributing factors to recent medication errors•New residents’ lack of familiarity with POE system•Strategies for coverage with decreased resident hours•Pain control issues/narcotics issues with patients with chronic pancreatitis, Interventional Radiology patients

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Best Practices: Engaging & Sustaining Nurse Involvement in CUSP

• Absolutely requires three strong champions: Nurse, physician, administration

• Monthly meetings require email reminders, individual invites, reminders throughout day, support to allow staff to step away from patients

• Energy maintained when you focus on what matters to the bedside nurse

• Really resolve some problems

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Lessons for Your Hospital: Strategies that Promote Nurses with the Leverage of CUSP

• If nurses are not engaged in the CUSP process, ask why

• Are you trying to lower CLABSI rates by ultimately requiring nurses to do more when they know they aren’t able to do half of what they expect of themselves?

• Find low-hanging fruit (e.g., need red labels on high-concentration PCA)

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Questions?