cusp communication & teamwork tools · • cusp improvement tools are designed for bedside...

6/20/2011

1

Welcome to CUSP Communication & Teamwork Tools

Coaching Call 1

The session will begin shortly.

To access the audio for the session,

Dial: 800-977-8002, Participant code 083842#.

The materials for this coaching call can be downloaded from the CUSP

Communication & Teamwork Tools password-protected web page. Directions

for how to access this web page can be found on each of the coaching call

meeting notices (appointments) sent to you.

The phone lines will be open during the presentation. Please keep your phone

on mute unless you are asking a question. If you do not have a mute function

on your phone, you can press *6 to mute your phone (and *6 again to unmute

if you want to ask a question). PLEASE DO NOT PUT YOUR PHONE ON HOLD!!!

If you experience any problems, please call Marilyn Nichols at the MOCPS office

at 573-636-1014, ext 221 or [email protected].

CUSP Communication &

Teamwork Tools

Pat Posa RN, BSN, MSA Kimberly O’Brien, MHA

System Performance Improvement Leader Project Manager

St. Joseph Mercy Health System Missouri Center for Patient Safety

Ann Arbor, MI Jefferson City, MO

[email protected] [email protected]

Coaching Call 1: Getting StartedLearning from Another Defect,

Assessing Current Rounding Practices, and

Exploring Structured Huddles

June 21, 2011

Document 1

6/20/2011

2

Participating Hospitals1. Barnes-Jewish St. Peters Hospital, St. Peters

2. Capital Region Medical Center, Jefferson City

3. Community Hospital – Fairfax, Fairfax

4. Fitzgibbon Hospital, Marshall

5. Jefferson Regional Medical Center, Festus

6. Missouri Southern Healthcare, Dexter

7. Ozarks Medical Center, West Plains

8. Saint Louis University Hospital, St. Louis

9. St. Luke’s Hospital, Kansas City

10. St. John’s Mercy Hospital, Washington

11. St. Luke’s Rehabilitation Hospital, Chesterfield

12. St. Mary’s Health Center, Jefferson City

13. Texas County Memorial Hospital, Houston

3

Documents for this Session(All can downloaded from the CUSP Communication & Teamwork Tools password-protected web site. Detailed instructions are

located on each of the coaching call meeting notices/appointments emailed to you by Kimberly O’Brien)

1. This PowerPoint presentation

2. Monthly Team Leader Checklist

3. Sample Agenda for June/July CUSP Team Meeting

4. MDR and Improving Teamwork Article

5. MDR and ICU Mortality Article

6. Lakeland Hospital Experience – daily rounds/goals

7. SJMHS Interdisciplinary Rounds Checklist

8. Henry Ford Health System Daily Goals Checklist

9. Improving Communication Using Daily Goals Article

10. Effective Communication Daily Goals Article

11. An audio file recording of this session will be emailed to

you shortly after the call today4

6/20/2011

3

Agenda

• Describe the project organization and goals of CUSP

Communications & Teamwork Tools

• Brief overview of CUSP

• Review Learn from a Defect

• Overview of Multidisciplinary Rounds with Daily

Goals

• Overview of Structured Huddles

• Identify next steps

• Answer questions

5

CUSP Communication & Teamwork ToolsProject Organization

• Monthly coaching calls will be held every third Tuesday of the month, from 12-1pm (beginning on 6/21/2011)

• Six coaching calls

• Coaching calls will be recorded

• Facilitated by Pat Posa, RN, BSN, MSA

• Team leaders will be provided agendas and materials for monthly unit team meetings (can be modified)

• Project deliverables: At end of 6 months, each unit will have implemented multidisciplinary rounds and/or huddles, and solved at least one defect– Submit Case Summary from Learning from a Defect Tool to

MOCPS by November 30, 2011

6

6/20/2011

4

CUSP Communication & Teamwork Tools

Prerequisites & Goals

• Prerequisites

– The Basics of CUSP

– Functioning CUSP team in place

– Executive and physician support

• Goals

– To implement multidisciplinary rounds (with daily goals) in

each participating unit

– To implement structured huddles in each participating unit

– To solve one defect, using the “Learning from a Defect”

methodology (introduced during The Basics of CUSP)

7

Unit-Based Patient Safety Culture

• Patient safety and quality happens at the local

level

• Build capacity at unit level to tackle multiple

problems

• Build capacity at the leadership level to

support unit-based safety culture

• Raise the quality and safety bar on the units

• Surviving the tsunami!

8

6/20/2011

5

Components of CUSP

1. Form a unit CUSP team with executive

sponsorship

2. Measure unit culture

3. Educate staff on Science of Safety

4. Identify defects using the Staff Safety

Assessment; prioritize defects

5. Learn from one defect per quarter

6. Implement team/communication tools

9

How is CUSP different?

• CUSP identifies problem areas –

– what staff think are impeding patient care vs. what

managers/directors think are priority areas

• CUSP improvement tools are designed for bedside

caregivers – easy for busy staff to use

– unit drives its own quality

• Lean/Six Sigma/CQI – focus more on streamlining the

process than identifying the problem areas

• CUSP can complement other quality improvement

methods – must use multiple tools!

10

6/20/2011

6

Learn from a Defect

• Designed to rigorously analyze the various

components and conditions that contributed to an

adverse event and is likely to be successful in the

elimination of future occurrences.

• Tool can serve to organize factors that may have

contributed to the defect and provides a logical

approach to breaking down faulty system issues

11

Learn from a Defect

• Select a specific defect

– What happened?

– Why did it happen (system lenses) ?

– What could you do to reduce risk ?

– How do you know risk was reduced ?

12

6/20/2011

7

Learn from a Defect Tool

Divided into three sections:

• Section 1 asks the users to identify what happened or the

defect they want to investigate

• Section 2 is a framework provided for the investigators to

identify any contributing factors. These factors include:

patient, task, caregiver, and team related, training and

education, local environment, information technology and

institutional environment.

• Section 3 asks participants to develop an action plan with

assigned responsibility for task completion and follow up

dates for each item.

13

Identifying a Defect

� AHRQ HSOPS results

� Staff safety assessment—how will the next patient be

harmed?

� Non-compliance with a core measure

� Event/incident reports

� Issues identified on Executive patient safety rounds

14

6/20/2011

8

Learning from Defects Tool

15

CUSP Communication & Teamwork Tools

Interventions

16

�Multidisciplinary Rounds with Daily Goals

�Structured Huddles

6/20/2011

9

• A strategy to assemble the patient care team members to

review important patient care and safety issues and improve

collaboration on the overall plan of care for the patient

• Improve communication among care team and family

members regarding the patient’s plan of care

• Goals should be specific and measurable

• Documented where all care team members have access

• Checklist used during rounds prompts caregivers to focus on

what needs to be accomplished that day to safely move the

patient closer to transfer out of the ICU or discharge home

• Measure effectiveness of rounds—team dynamics,

communication, quality measure compliance, LOS

Multidisciplinary Rounds with Daily Goals –

What is it?

17

Evidence For Impact Of MDR Rounds

• Research studies on the effect of structured interdisciplinary rounds show:

– Earlier identification of clinical issues

– More timely referrals

– Improved ratings by nurses and physicians on teamwork, communication and

collaboration.

• Research also indicates variable effects on LOS and cost, with some studies

showing improvement and others having no impact.

Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching

unit.

O'Leary KJ, et. al, Journal Of General Internal Medicine [J Gen Intern Med], ISSN: 1525-1497,

2010 Aug; Vol. 25 (8), pp. 826-32; PMID: 20386996

(Document 4 of your materials for this coaching call)

18

6/20/2011

10

The Effect of Multidisciplinary Care Teams on Intensive

Care Unit MortalityArch Intern Med Feb 22, 2010

19

• Retrospective cohort study (using state discharge data from

Pennsylvania Health Care Cost Containment Council)

• 112 hospitals

• Non-cardiac, non-surgical ICUs

• 30 day mortality

• Looked at 3 types of multidisciplinary care models

•multidisciplinary care staffing alone

•intensivist physician staffing alone

•interaction between intensivist physician staffing

and multidisciplinary care teams

The Effect of Multidisciplinary Care Teams on Intensive

Care Unit MortalityArch Intern Med Feb 22, 2010

Association Between Intensivist Physician Staffing and 30-Day Mortality for All Patients

Variable OR (95% CI) P Value

Model 1: multidisciplinary care staffing alone

– No multidisciplinary care 1 [Reference]

– Multidisciplinary care 0.84 (0.76-0.93) .001

Model 2: intensivist physician staffing alone

– Low intensity 1 [Reference]

– High intensity 0.84 (0.75-0.94) .002

Model 3: interaction between intensivist physician staffing

and multidisciplinary care teams

– Low intensity+ no multidisciplinary team 1 [Reference]

– Low intensity + multidisciplinary team 0.88 (0.79-0.97) .01

– High intensity + multidisciplinary care 0.78 (0.68-0.89) .001

20

6/20/2011

11

• Should be done in ICUs and all units in hospital

• Hard initiative to implement, especially if you have an open unit

and/or no intensivists or in non-ICU area

– Standardize the structure and process for all units

– Benefits seen even if physician can not attend consistently or at all

– Second rounds should be done in afternoon—include at least

physician and bedside nurse

• Evaluate if goals for day have been met; readjust if necessary

• Identify if patient can be discharged (or transferred ) the next

day and if so, what needs to be accomplished

• Focused first on defining daily goals and recording those either on the

white board in the room or on a sheet of paper

• Then standardize rounds—who should attend and what is discussed

• Implemented checklist or nursing objective card

Multidisciplinary Rounds with Daily GoalsChallenges and Opportunities

21

Multidisciplinary Rounds with Daily Goals

Steps to Implementation

1. Commitment by all that MDR with daily goals is a strategy

that will be implemented to improve communication and

patient outcomes

2. CUSP team takes on initiative—identify if there are any

additional team members needed

3. Evaluate current rounding process

4. Identify gaps between current process and what you want it

to look like

5. Define the standard work of rounds, roles and

responsibilities of each member and develop checklist and

goal process

6. Define metrics to evaluate MDR

22

6/20/2011

12

Standardized Work Paradigm

Old Paradigm - I know you’ll be able to figure it out.

Just get it done the best way you can.

New Paradigm - In order to have consistent results

we must do things the same way every time.

23

Standard Work System

• Standardized Work is a system for achieving a stable

baseline for a process in order to systematically

improve it.

• Standardized Work Systems are the basis for

Continuous Improvement.

“What you permit, you promote”

“We deserve what we tolerate”

24

6/20/2011

13

Current State AssessmentResults of this assessment should be entered into Survey Monkey by July 8th using this URL:

http://www.surveymonkey.com/s/Z3KVYSQ

What is the state of rounds on your unit?1. Describe the structure of the participating unit(s). For example, the type of unit

(i.e. ICU, Med Surg, Ancillary), whether the unit is open or closed, whether or not

the unit has intensivists or hospitalists, how many beds the unit has, etc.

2. Are rounds currently held on the participating unit(s)?

3. How often are rounds held?

4. Who usually attends rounds?

5. What are the roles of each member?

6. Where do rounds usually take place?

7. Is there a defined structure/process for rounds? If so what is it? Or does it depend

on who is running them?

8. Are daily goals part of the rounding structure/process?

9. How have rounds made a difference during the past year in improving the

performance on your unit?

10. What is the major barrier for multidisciplinary round implementation on your unit?

25

Patient Daily Goals Form(Document 6 of Coaching Call Materials)

26

6/20/2011

14

Interdisciplinary Critical Care Plan and Daily Goals – CCU

Relevant System / Discipline Key: “Yes” = issues identified needing to be addressed (list issues) “No” = no issues identified (Information in parentheses is the standard patient goal –

check in daily column whether specific need identified)

Date:

Time: Initials:

Date:

Time: Initials:

Date:

Time: Initials:

Date:

Time: Initials:

Goal(s)

Patient greatest safety issue

Lab work / tests

Tests / Procedures for today

Admit Culture

Hgb Hct

K+ Cr+ CPK Troponin

HgA1C Culture

Hgb Hct

K+ Cr+ CPK Troponin

HgA1C Culture

Hgb Hct

K+ Cr+ CPK Troponin

HgA1C Culture

Hgb Hct

K+ Cr+ CPK Troponin

Neurologic (alert / oriented w/o

deficit)

� Yes � LOC � No � Seizure Precautions




Cardiovascular LVEF Measurement:ECHO____________

Coronary Cath ____________

ICD / PPM

� Yes Rhythm

� No Vasopressors Antiarrythmic

� Need for anticoagulation

� Yes Rhythm



� Yes Rhythm



� Yes Rhythm



Respiratory / vent management Date Intubated

Date Extubated

Reintubation required

Combivent / Nebs

ARDS: Low TV management

� Yes O2 SpO2

� No � HOB �� 30O

� Smoking cessation Vent � Yes � No � RSBI

� Daily weaning trial completed

� Sedation vacation MAS score � Oral care every 2 hours

� Yes O2 SpO2

� No � HOB �� 30O




� Yes O2 SpO2

� No � HOB �� 30O




� Yes O2 SpO2

� No � HOB �� 30O




Renal / Fluid Status Baseline Cr

Output goals

Recognize Daily weight gain / loss

� Yes Dialysis � Yes � No

� No

Ready to DC urinary catheter � Yes � No


� No



� No



� No


GI / Nutrition Baseline Prealbumin

Enteral tube feeding protocol Supplements/speech evaluation

Document malnutrition

Bowel management

� Yes � Stress bleeding prophylaxis

� No � Tolerating present nutrition

� Diet

� Tolerating TF � Goal Rate

� Last BM



� Diet


� Last BM



� Diet


� Last BM



� Diet


� Last BM

Endocrine Glucose control: Goal 80 – 120, if intubated,

blood sugar every 6 hours. If blood sugar

121 – 149, initiate diabetic management orders. Hypoglycemia protocol utilized

� Yes � Insulin gtt

� No � SSI

� Glucose 80 – 110 mg/dL � Steroids


� No � SSI



� No � SSI



� No � SSI


Pain / Sedation medications Goal to remain calm and pain managed at

acceptable level

� Yes � Sedation protocol utilized

� No � Treatment







6492-016-W-2s-3 (Rev. 02-07-05

Daily Goal Sheet

27

(Information in parentheses is the standard patient goal –

check in daily column whether specific need identified)

Date: Initials: Date: Initials: Date: Initials: Date: Initials:

Activity – Skin – Mobility (Adequate activity progression, no skin

breakdown)

“If Braden < 18 at risk for skin breakdown”

� Yes � No � PT consult � ROM

� DVT prophylaxis � Consult ET RN

� Dressing, wound, incision

� Pressure ulcer prevention standard � Impaired skin management standard













VAD

� Yes Temp

� No � Readiness to DC

Arterial Line Day # ER/Elective

Central Line Day # ER/Elective

Peripheral IV Day # ER/Elective

� Yes Temp





� Yes Temp





� Yes Temp





Safety / Restraints � Yes

� No

� Assess need every 2 hours

� Order obtained

� Yes

� No


� Order obtained

� Yes

� No


� Order obtained

� Yes

� No


� Order obtained

Family – Psychosocial – Spiritual (No ethical concerns, e.g., end of life issues,

financial issues)

Spokesperson

� DPOA � Living Will

� Yes Code Status

� No

� Family Conf. (LOS>3 Days)

Plan of care reviewed with pt/family

� Yes � No

� Financial Services Consult

� Social Services Consult

� Yes Code Status

� No



� Yes � No



� Yes Code Status

� No



� Yes � No



� Yes Code Status

� No



� Yes � No



Discharge / Transfer Plans Long term discharge goal

� Yes � No

Ready to discharge from CCU?

� Yes � No

ECF Planning � Yes � No


� Yes � No


� Yes � No



� Yes � No


� Yes � No



� Yes � No


� Yes � No



Medication Review (no concerns re: IV

to PO, home med, renal adjustments, sedation

requirements, new allergies, adverse reaction,

unnecessary medications)

� Yes � No

Can any be discontinued?

IV to PO

� Yes � No


IV to PO

� Yes � No


IV to PO

� Yes � No


IV to PO

Other patient specific issues /

Other needed consults

AMI / ACS Indicators Cardiac Cath

ACE for EF < 40%

� Yes Plavix

� No Aspirin

Beta Blocker

ACE / ARB

Lipid lower

� Yes Plavix

� No Aspirin

Beta Blocker

ACE / ARB

Lipid lower

� Yes Plavix

� No Aspirin

Beta Blocker

ACE / ARB

Lipid lower

� Yes Plavix

� No Aspirin

Beta Blocker

ACE / ARB

Lipid lower

CHF Indicators ACE for EF < 40%

� Yes ACE

� No ARB

� Yes ACE

� No ARB

� Yes ACE

� No ARB

� Yes ACE

� No ARB

RN Signature Date:

Time: Date:

Time: Date:

Time: Date:

Time:

Intensivist Signature Date:

Time: Date:

Time: Date:

Time: Date:

Time: � Physician � PCM � RN � Physician � PCM � RN � Physician � PCM � RN � Physician � PCM � RN

� Pharmacy � RT � SS � Pharmacy � RT � SS � Pharmacy � RT � SS � Pharmacy � RT � SS

� PT � Dietary � Chaplain � PT � Dietary � Chaplain � PT � Dietary � Chaplain � PT � Dietary � Chaplain

� Palliative Care � Other � Palliative Care � Other � Palliative Care � Other � Palliative Care � Other

Daily Goal Sheet (continued)

28

6/20/2011

15

Nursing Card(see Document 7 of the Coaching Call materials – SJMHS Interdisciplinary Rounds Checklist)

VAP

Delirium

Sepsis

29

• Enable teams to have frequent but short briefings so that they

can stay informed, review work, make plans, and move ahead

rapidly.

• Allow fuller participation of front-line staff and bedside

caregivers, who often find it impossible to get away for the

conventional hour-long improvement team meetings.

• They keep momentum going, as teams are able to meet more

frequently.

Structured Huddles

Use this strategy to begin to recovery immediately

from defects---IE: falls, sepsis and daily to focus on

unit outcomes

30

6/20/2011

16

31

Components

Metric 1: Quality/Safety

Metric 2: Patient Satisfaction

Metric 3: Operations

Daily Critical Communications

Information

Ideas in Motion

How to do it?

•Beginning or mid shift

•5 minutes

•Lead by member of unit

leadership team

SICU Huddle Board

32

6/20/2011

17

CUSP Communication & Teamwork ToolsNext Steps

• Multidisciplinary Rounds– Complete Current State Assessment (See Slide 25)

– Submit answers through Survey Monkey: http://www.surveymonkey.com/s/Z3KVYSQ

– Due by Friday, July 8th

• Learning from a Defect– Identify next defect to solve

– Make any additions/deletions to team membership

• Structured Huddles– Review the concept with unit leadership and CUSP team, gather questions

– Questions will be answered/discussed during Coaching Call 2 on July 19th

• CUSP Team Agenda (see Document 3 of Coaching Call Materials)– Choose next defect to take through the Learning from a Defect Tool

– Review multidisicipnary rounds slides; complete current state assessment

– Review structured huddle slides; get feedback/questions from CUSP team and unit leadership for next Coaching Call

– Ensure that concepts of Multidisciplinary Rounds and Structured Huddles are vetted by

executive sponsor for unit and VPMA/CMO

33

We Are On a Continuous Journey

• We have toolkits, manuals, websites, and monthly calls to

learn from and with each other.

• Your job is to join the calls, share with us your successes

and more importantly the barriers you face.

• Commit to the premise that harm is untenable.

34

6/20/2011

18

Questions?

35