hawaii surgical unit safety program: the journey begins with the comprehensive unit-based safety...
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Hawaii Surgical Unit Safety Program: The Journey Begins with the Comprehensive Unit-Based Safety
Program
May 21, 2013Della M. Lin, M.D.
Hawaii Safer Care SUSP
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“the most common cause of failure in leadership is produced by treating adaptive challenges as if they
were technical problems.”
Ron Heifetz
Comprehensive Unit-based Safety Program (CUSP)
• Assign executive to adopt unit
• Educate staff on science of safety
• Identify defects
• Learn from one defect per month/quarter
• Implement teamwork tools
Pronovost J, Patient Safety, 2005
It Takes Three!
Robust DataImplementation of Evidence-Based Measures
Effective Safety Culture
Hawaii CUSP-CLABSI collaborative
Hospital Acquired Infections (CLABSI) SIR scores: CMS Hospital Compare
• PR 1.58• MS 0.91• MD 0.87• ME 0.84• LA 0.81• RI 0.76• MH 0.76• TN 0.72• AL 0.72• MT 0.69• SC 0.67• NJ 0.67• WV 0.66• NY 0.66• DC 0.63
• KS 0.33• MI 0.32• SD 0.24• HI 0.17
• IL 0.50• WY 0.49• VT 0.48• OR 0.47• PA 0.46• MO 0.46• ID 0.45• OH 0.44• AR 0.44• WA 0.42• IN 0.41• MN 0.38• DE 0.37• ND 0.37• AK 0.35
• VA 0.62• NE 0.59• OK 0.58• GA 0.58• WI 0.55• CA 0.54• WI 0.54• UT 0.54• CO 0.53• TX 0.52• NM 0.52• NC 0.51• IA 0.51• Fl 0.51• MA 0.50
Accessed 8/20/2012 http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalCompare.html
“During the 36-month study period, the overall CLABSI rate was reduced by 82%...
…Importantly, the tools were not viewed as simple technical interventions but were instead designed as interventions with an adaptive component that would shape a culture of safety.”
SUSP
Technical – Practices to Prevent Harm
Evidence Based Practice
1. Audit Tools Education on the Evidence
1. Presentation of evidence
2. Fact Sheet3. Cost Estimator4. Summary of
Professional Organization Recommendations
5. Annotated bibliography
Implementation/
Sustaining
1.Checklist 2.Policy /
Procedures 3. Protocol s4. Monitoring6. Feedback
Adaptive (CUSP)
Science of Safety
1. Science of Safety presentation
2. Attendance sheet
Staff Identify Defects
1.Staff Safety Assessment form
2.Identifying Hazards presentation
Senior Executive Partnership
1. Education2. Briefings
Learning from Defects
1. LFD toolkit2.RCA of each
incidence
Implement Tools for Teamwork and
Communication
1. Surgical Safety Briefing 2. Huddles 3. Debriefing 4. Shadowing 5. Handoff Tool6. TeamSTEPPS
Tools
Assemble a SUSP team, Partner with a Senior Executive;
Baseline Data
Quality Improvement
Tools 1. PDCA2. Lean/Six
Sigma3. Reliable System
Process4. TCAB 5. Other
Comprehensive Unit-based Safety Program (CUSP)
• Assign executive to adopt unit
• Educate staff on science of safety
– Acknowledge safety is a property of a system– Standardize what you can– Use safe design principles
• Identify defects
• Learn from one defect per month/quarter
• Implement teamwork tools
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What makes CUSP unique?
• Pearls for the CUSP approach
– Horizontal: Comprehensive UNIT-BASED approach
– Vertical: Intentional Executive Leadership role and participation
– Trans Dimensional: Multidisciplinary Team Tools for ensuring diverse and independent input
– Adaptive: Leverage tools that promote behavior change to model mental model change
What will you do differently? How will you do it differently?